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154 Cards in this Set
- Front
- Back
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o What are the common causes of acute agitation? |
§ Mania § Psychosis § Anxiety disorder § Personality Disorder § External factors – noise, discomfort, pain causing anxiety and agitation § Paradoxical sedative drug effects § Alcohol withdrawal § Sepsis § Psychoactive drug use |
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o What are the individual and epidemiological risk factors for suicide? |
§ SADPERSONS: · Sex – male · Age >60 · Depression · Previous attempts · Ethanol Use · Rational thinking loss · Social support lacking · Organized plan · No partner/spouse · Sickness |
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o What factors may determine suicidal intent? |
§ Plan for suicide § Access to means § Previous attempts § Mental/physical illness § FHx suicide § Impulsivity § Drug use § Perceived intent to carry out § Future plans/goals/motivational factors § Protective factors such as family
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o Management of suicidality (assessment, prevention, treatment) |
§ Assessment · Hx and risk assessment · Plans for suicide · Patient’s motives § Prevention · Intervention at early stage of risk · Removal of objects of harm – firearms, drugs § Treatment · Antidepressant therapy · ECT · CBT · Family Supports
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o Besides suicide and aggression, what are the other risks that a clinician may need to consider in the clinical setting?
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§ Medical stability · Intoxication · Withdrawal · OD · Neuroleptic malignant syndrome § Harm to self § Harm to others § Absconding § Infectious risk
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o In what ways can you conceptualise risk/ what is the typical format for a psychiatric risk assessment? |
§ Self Harm · Static – Prev. attempts, FHx suicide · Dynamic – ongoing ideation, hopelessness, major life changes § Risk to others · Static – prev. violence, antisocial personality · Dynamic – homicidal fantasies, poor self control, access to weapons § Mental instability · Obvious symptoms of mental illness that interfere with judgment and ADLs § Vulnerability · Physical illness, disability, falls, poverty
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o Which de-escalation techniques do you know? What is their underlying principle? |
§ Calm unimposing approach § Introductions and asking “how can I help” § Acknowledge emotions of the patient and empathise § Offer alternatives § Offer choices to return control
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o When would you consider using physical restraint in a clinical setting? |
§ Admission of medicine safely to agitated invidual § When pt is danger to self or others
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o When would you consider using medications in the acute management of agitation? |
§ Depends on level of agitation § Low agitation · Lorazepam PO 2mg · Olanzapine PO 10mg § Moderate · Clonazepam IM 2mg · Olanzapine IM § High · Zuclopanthixol IM 100mg · Clonazepam IM 2mg
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o What do you understand by the term delirium?
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§ Delirium - Acute onset of fluctuating cognitive impairment + disturbance of consciousness. Hallmark is impaired consciousness |
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o What are the core clinical features of delirium? |
§ Rapid onset: · Disorientation · Confusion · Cognitive impairment § Rapid improvement when causative factor is removed § Altered: · Consciousness · Cognition · Fluctuating course § Delirium vs dementia – acute vs chronic, fluctuating vs stable, reversible vs irreversible
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o What are the most common causes of delirium? |
§ Substance induced withdrawal / intoxication § Infection and sepsis § Head trauma § Metabolic disturbances – altered blood glucose, renal/hepatic failure § dehydration |
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o What do you understand by the term dementia?
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§ Syndrome of Impaired cognitive function accompanied by decline in functioning § Multiple cognitive deficits including: · Memory impairment · Executive functioning · Apraxia, aphasia, agnosia § Consciousness is not disturbed, global impairment of intellect essential feature
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o List the different forms of dementia, starting with the most common one. |
§ Alzheimer’s Disease § Dementia w/ Lewy bodies § Fronto-temporal dementia § Vascular dementia § Other causes · B12 deficiency · HIV / neurosyphilis · Wilsons disease · Dementia Pugilistica · Alcohol
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o What are the defining clinical features of the most common forms of dementia? |
§ Alzeheimers · Memory loss · Nominal aphasia · Personality Change · Apathy § Dementia W/ Lewy Bodies · Cognitive impairment · Fluxuations in mental state/consciousness · Extrapyramidal signs (parkinsonianism – rigidity, bradykinesia, tremor) · Hallucinations and delusions § Fronto-temporal dementia · Personality disturbances · Disinhibition · Memory impairment · Memory impairment and disorientation § Vascular dementia · Disinhibition · Apathy · Poor attention · Primitive reflexes |
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o What are the risk factors and causes of dementia?
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§ Age >65 § Female gender § Vascular risk factors § Protective · Higher level education · Mentally active · Social engagement · Regular exercise
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o What do you understand by the term Pseudodementia?
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§ Symptoms consistant w/ dementia but caused by pre-existing psych. Illness § Causes · Depression · Medications § Acute onset |
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o What do you understand by the term confabulation and in which conditions does it typically arise?
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§ Unconsciousness creation of memories or delusions due to memory deficits without intention to deceive. § May perceive confabulated memories to be true § Provoked – response to questions § Spontaneous – made without cues § May be filling in the blanks with actual memories § Caused by: · Korsakoff’s syndrome · Alzeheimer’s Disease · Sometimes Schizophrenia · Traumatic Brain injury to right inferior-medial frontal lobe
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o In an elderly patient who presents with depressive features, how would you differentiate clinical features compatible with depression from those of an early dementia?
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§ Pseudodementia Depression: · More prominent depressive symptoms · More insight · Past hx of depressive episodes · Cognitive deficits improve after antidepressant therapy § Dementia: · Difficult to pinpoint beginning of onset · Pt don’t usually notice cognitive loss · Attention initially intact
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o What are the common neuropsychiatric presentations and complications of Parkinsons disease?
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§ Depression § Drug-induced psychosis § Impulse control disorders § Cognitive impairment § Dementia in late stage disease
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o What are the common neuropsychiatric presentations and complications of epilepsy?
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§ Psychosis of epilepsy · Post-ictal psychosis · Ictal psychosis o Non-convulsive status epilepticus (absence seizures, complex partial seizures) § Somatic Sensations § Vision disturbances § Autonomic functional disturbances – flushing, sweating, piloerection
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o What are the common neuropsychiatric presentations and complications of disorders of thyroid function
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§ Hyper: · Depression (most frequent at 30%) · Concentration and attention impairment · GAD · Psychosis in 5% § Hypo: · Psychosis (myxedema madness) · Cognitive deficits · Depression
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o What are the common neuropsychiatric presentations and complications of the various connective tissue disorders?
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§ SLE · Acute confusion · Lethargy · Chronic dementia · Depression · Psychosis
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o What are the common neuropsychiatric presentations and complications of multiple sclerosis?
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§ Fatigue – mental + physical § Dysphoria § Anxiety § Agitation § Irritability § Major depressive disorder § Cognitive impairment
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o What clinical symptoms define substance dependence?
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§ Substance dependence – maladaptive pattern of substance use interfering with function, in a 12 month period with: · Tolerance · Withdrawal · Larger amounts / longer period of time · Persistent desire to cut down · Excessive time to procure, use, or recover from substance · Interests/activities given up/reduced · Continued use despite problems § Substance abuse – maladaptive pattern of substance use interfering with function in 12 month period of recurrent: · Use resulting in failure to fulfil major role obligations · Use in situations where it is physically hazardous · Recurrent substance related legal issues · Continued use despite interference in daily activities § ABUSE is a presence of one or more of 4 significant recurring psychosocial, interpersonal or legal problems related to use. § DEPENDENCE is 3 or more of 7 severe, recurring problems related to use within a 12 month period and include tolerance, withdrawal and compulsive use |
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o What are the CAGE questions and what is their value in the clinical setting?
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§ Screening questions for alcohol · Cut down · Annoyed at criticism for drinking · Guilty about drinking · Eye-opener in the mornings § 2 yes out of 4 = alcohol problem |
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o What are the clinical features of alcohol withdrawal and how do they differ from delirium tremens?
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§ Withdrawal · Nausea + vomiting · Tremor · Paroxysmal sweats · Anxiety · Agitation · Tactile, auditory, visual disturbances · Headache § Delirium Tremens · Acute reaction to alcohol withdrawal, 2-10 days post cessation · Defined by o Symptoms of delirium o Autonomic hyperactivity (tachycardia, fever, hyperhidrosis, dilated pupils) o Perceptual distortions (visual + tactile hallucinations) o Fluctuating levels of psychomotor activity · Mortality 20%
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o What are the common medical and psychiatric complications of abusing the following substances: § Psychostimulants |
· Medical o Weight loss o Appetite suppression o Headache o Insomnia · Psych o Chronic psychosis o Drug induced psychosis o Mood instability o Unpredictable behaviour and violence
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o What are the common medical and psychiatric complications of abusing the following substances: § Cannabis
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· Medical o Tachycardia o Tremors o Red eyes o Respiratory problems · Psych o Anxiety o Mania o Phobias o Depressive disorders o Drug induced psychosis
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o What are the common medical and psychiatric complications of abusing the following substances: § Narcotics (opioids)
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· Medical o Respiratory depression o Pupillary constriction o Nausea + vomiting o Constipation · Psych o Social dysfunction o dependence
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o What are the common medical and psychiatric complications of abusing the following substances: § Benzodiazepines
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· Medical o Respiratory depression o Falls in elderly o Sedation · Psych o Cognitive impairment o Long term use – anxiety § Anhedonia § depression · Paradoxical effects o Aggression o Irritability o impulsivity
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o What are the common medical and psychiatric complications of abusing the following substances: § Solvents |
· Medical – other effects depend on what substance is inhaled o Headache o Nausea and vomiting o Slurred speech o Motor impairment o Wheezing o pneumonia · Psych o Organic brain damage – possibly brain hypoxia o Paranoid psychosis o Temporal lobe epilepsy o Decreased IQ
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o How would you define the term psychosis
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§ Grossly impaired reality testing – loss of contact with reality · Misinterpretation and misapprehension of reality, includes disturbances in: o Perception - hallucinations o Belief - delusions o Disorganized speech patterns – thought disorder
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o What are the clinical features of psychosis?
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§ Hallucinations · Perceptions in absence of stimuli o Auditory o Visual o Olfactory o Gustatory o Taste § Delusions · Fixed, false beliefs held despite evidence to contrary, cannot be accounted for by culture, religion or upbringing · Systematized/unsystematised · Types o Persecutory – conspired against o Sin/guilt – commited something bad o Grandiose – unrealistic belief in one’s own abilities o Reference – insignificant remarks or events refer to them/special meaning o Somatic – somehow they are diseased o Religious – false beliefs of religious nature o Nihilistic – believes they have died o Passivity – being controlled o Thought alienation § Thought broadcasting § Insertion § Withdrawal o Erotomania – believes they are in love and loved by a stranger § Disturbed Behaviour · Due to delusions or command hallucinations § Disordered Speech · Thought disorders – loosening of associations § Abnormal Feelings · Mood swings · Anxiety · Feelings of unreality · Emotional flatness
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o What do you understand by the term formal thought disorder?
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§ Formal thought disorder – when patients thinking is incomprehensible to others and appears illogical § Disturbances to connections between ideas – structure and form of thinking
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o List some common terms used to describe formal thought disorder and explain what these terms mean.
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§ Loosening of associations (derailment) – disconnected ideas - unrelated § Tangentiality – replies to question in oblique tangential manner § Circumstantiality – indirect and delayed in reaching goal ideas § Blocking – halted speech mid sentence, picked up moments later in a different place – possibly interrupted by intrusive thoughts § Over-inclusiveness – disruption of flow by including irrelevant information § Flight of ideas – excessive speech at rapid rate involving fragmented or unrelated ideas § Neologisms – coining of new words § Clang association – next words chosen based on sounding § Echolalia – repetition of words/phrases said by others § Perseveration – phrases persistently repeated § Abstraction · Transitory – non-permanent thinking – derailments, substitutions etc. · Drivelling – non-sense thinking, muddled ideas · Desultory – jumping thoughts, lacking plan, sudden ideas force into thoughts
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o List some typical clinical manifestations of catatonia.
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§ Disturbance in motor function w/ decrease in reactivity to environment · Abnormalities in execution of movement o Catatonic excitement o Catatonic stupor o Catatonic posturing o Catatonic rigidity · Abnormal movement when interacting with others o Wavy flexibility o Echopraxia o Catatonic negativism o Automatic obedience
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o What are the most important differential diagnoses of a first presentation with psychosis in an adolescent or young adult?
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§ Medical causes – delirium § Drugs – amphetamines, cannabis, alcohol § Mood disorders – depression w/ psychosis, mania w/ psychosis (bipolar), § Schizophrenia – schizophreniform, brief psychotic, schizoaffective, delusional § Medication · Bupropion · Fluoxetine · Dopaminergics § Organic · Hypo/hyperthyroidism · Electrolyte abnormalities · SLE · Epilepsy · HIV/aids
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o Which illegal psychoactive substances are most commonly associated with drug-induced psychosis in Australia?
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§ Cannabis § Cocaine § Amphetamine § Alcohol § Hallucinogenics § Ecstasy § Phencyclidine (PCP)
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o What are the most common differential diagnoses of a first presentation with psychosis in an elderly patient?
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§ Delirium w/ psychotic features § Dementia § Medical Illness · Parkinsons, epilepsy, Neurosyphilis · Hypothyroidism, cerebral SLE, paraneoplastic syndrome
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o What are the most important differential diagnoses of recurrent episodes of psychosis?
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§ Schizophrenia + related disorders § Delusional disorder § Schizoaffective § Mood disorders – Major depression, bipolar w/ psychosis
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o What are the main symptom domains of Schizophrenia? How do these domains affect the functioning of a person with this condition? § 4 domains: |
· Positive symptoms o Hallucinations o Delusions o Disorganized speech and behaviour · Negative symptoms o Decrease in emotional range o Poverty of speech o Loss of interest and drive · Cognitive symptoms o Attention and memory deficits · Mood symptoms o Unstable mood § DSM: · 2 or more of symptoms for 1 month: o Delusions o Hallucinations o Disorganized speech o Disorganized or catatonic behaviour o Negative symptoms (Affective flattening, alogia or avolition) · Social dysfunction: o Self care o Interpersonal relations o Work § First rank symptoms: · ABCD: o Auditory Hallucinations o Broadcasting of thought o Controlled thought o Delusional Perception
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o What are the clinical features of the negative syndrome in schizophrenia?
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§ Alogia – poverty of speech § Blunting of affect – reduced intensity of emotions § Avolition – no motivation § Anhedonia – no pleasure § Apathy – lack of emotional resonance
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o Which clinical features would you see in a person with prodromal schizophrenia?
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§ Social Withdrawal § Work impairment § Emotional Blunting § Lack of motivation § Strange ideations § Cognitive decline
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o List some of the epidemiological factors associated with Schizophrenia. |
§ 1% prevalence § Same ratio of male to female § Between 15 and 30 years of age § Cannabis use § Urban living § Long prodromal period § Occurrence of negative symptoms § Associated with insulin resistance
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o List some typical neuropathological abnormalities, which can be found in the brains of people with schizophrenia. |
§ 5-10% reduction in brain volume § Enlargement of lateral and third ventricles § Decreased volume of prefrontal cortex, hippocampus and amygdala § Reduction in activation of prefrontal cortex § Dopamine, glutamate, GABA implicated § Reduced neuronal size
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o Which neurotransmitter systems are thought to be involved in the pathophysiology of schizophrenia?
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§ Dopamine – mesocephalic nuclei pathways · Mesostriatal – movement disorders · Mesolimbic – positive symptoms · Mesocortical – cognitive deficits § Glutamate § GABA
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o Reasons of high medical comorbidity and reduced lifespan in schizophrenics
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§ Mean age of death 50s § Increased co-morbid illnesses · CVD · Metabolic syndrome · Respiratory disease § Mediators · Smoking and substance abuse · Lifestyles – SE status, sedentary lifestyle · Medication adverse effects – antipsychotics
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o What clinical features would persuade you to make a diagnosis of schizoaffective disorder as opposed to schizophrenia or bipolar disorder?
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§ Schizoaffective: · Major depressive, manic, or mixed episodes that are present when ill that are separate from schizophreniform symptoms (disordered thought, hallucinations, delusions). Mood disorder Free psychosis · Presence of positive symptoms for 2 weeks without mood symptoms § Schizoaffective needs 2 weeks where mood symptoms are not present, but hallucinations or delusions are present § Schizophrenia – no mood component, instead there are negative symptoms § Bipolar – no schizophreniform symptoms, but mania + depression present for >1 week § Schizoaffective – middle ground between bipolar (more mood, little positive symptoms) and schizophrenia (little mood, more positive symptoms)
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o What clinical features would persuade you to make a diagnosis of delusional disorder as opposed to schizophrenia? |
§ Delusional disorder · Chronic non-bizarre, systematised delusions, without cognitive or functional deterioration · Criterion for schizophrenia not met · Delusion lasts for >1 month · Duration of mood episodes is less than that of the delusions -
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o What are the main clinical symptom domains of depressive disorders?
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§ Mood · Depressed mood · Anhedonia · Restricted reactivity · Amotivation · Anergic § Psychomotor activity · Agitation/retardation § Cognition · Hopelessness/helplessness · Poor concentration · Impaired executive functions § Neurovegetative · Loss of libido · Weight gain/loss · Fatigue · Disturbed sleep – early morning wakening · Diurnal variation
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o What are the main clinical symptom domains of bipolar disorders?
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§ Domains: · Mood o Elevation of mood o Irritability o Lability · Psychomotor o Motor activation o Flight of ideas o Pressured speech · Cognitive o Grandiosity o Expansive view of the world o Mood congruent delusions · Vegetative o Decr. Need for sleep o Hypersexuality o Impairment of judgement and insight § Bipolar mood disorder – characterised by mania, alone or in combination with depression § Rapid cycling – 4 manic/hypomanic and depression episodes a year
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o What is the main difference between bipolar I and bipolar II disorders according to DSM?
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§ Bipolar 1 has mania whilst bipolar 2 has hypomania § Cyclothymic disorder – fluctuating mood disturbance, chronic and consisting of various periods of hypomania and depressive symptoms § Bipolar I · Mania o Compromised functioning o Presence of Psychosis § Bipolar II · Hypomania o Symptoms of mania save for psychotic symptoms o Absence of psychosis
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o What are the main clinical features for mixed episode and what is its clinical significance?
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§ Increased possibility of suicide § Both mania and depressive episodes nearly every day for a week
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o How is mania different from hypomania?
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§ Mania vs Hypomania § Mania – Marked impaired functioning, presence of symptoms of psychosis § Hypomania – No symptoms of psychosis present, however patients still have a persistent and highly elevated mood
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o How is an adjustment disorder different from depressive disorders?
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§ Adjustment disorder: stress related short term non-psychotic disturbance § Symptoms of depression, however not sever enough to be classified as a major depressive episode § Additionally symptoms lessen within 6 months once stressor is removed
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o What do you understand by the term dysthymic disorder?
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§ Unipolar mood disorder, chronically unhappy and miserable. § Depressed mood accompanied by neurovegetative symptoms and impaired cognition § 3:1 women to men ratio
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o What do you understand by the term mood-congruent delusions?
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§ Consistent with mood disorder. I.e. depressed = guilty of something, manic – delusions of grandiosity |
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o What medical conditions are typically associated with depression, or present with depression as a major clinical features?
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§ Cancer § Infections – Mononucleosis, hepatitis § Endocrine – Hypo-hyper thyroidism, diabetes, cushings, phaeochromocytoma § Anaemia § Nutrition and electrolyte disturbance – hypercalcaemia, hyponatremia, vit D deficiency § Neurologic – Epilepsy, Head trauma § Post Myocardial infarction, menopause
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o Which body systems have been associated with the aetiopathogenesis of mood disorders.
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§ Decr. Volumes of hippocampus and ant. Cingulate gyrus § Changes in brain regional metabolism § Neuroendocrine – HPA axis § Immune
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o List some epidemiological risk factors for developing a mood disorder. |
§ Gender – Females 2:1 ratio § Age – Bipolar <20 years § Dysthymia <20 years § MDD 30-35 § FHx of mood disorders § Life stressors § Parental divorce
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o What do you understand by the terms personality, personality traits and personality disorder?
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§ Personality - Persistent and integrated pattern with which a person perceives their internal experience and interacts with the world in general. · Made of temperament (emotional core) and Character (conceptual core) § Personality trait – Aspect of personality – enduring and stable aspect of a persons internal world or external behaviour · Personality is integration of these aspects § Personality disorder · Enduring and stable pattern of inner experience and behaviour that deviates markedly from expectations of individual’s culture, which is inflexible and pervasive leading to functional impairment and clinically significant stress.
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o Why is it important to take a detailed accurate longitudinal developmental history when considering a diagnosis of a personality disorder?
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§ Individual’s developmental history is a major contributing factor that shapes personality throughout childhood and adolescence § Not consolidated until adulthood § Stressors + environment significant in development of personality disorder
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o How would you go about explaining the concept of personality disorder to a patient?
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§ Degree of variance of normality § Experiences and our environment shape our personality § There are personality states which are made of certain traits which may be problematic for an individual such that they deviate far from what is considered a mean in terms of behaviour.
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o List the personality disorders as they are set out in dsm-5 and describe the core clinical features of each. (A-3, B-4, C-3) |
§ Cluster A – Mad – Schizotypal, Schizoid, Paranoid · Overarching trait of odd, eccentric and socially detached, associated w/ schizophrenia and psychosis · Schizotypal – pervasive pattern of acute discomfort and limited capacity for close relationships, with rich inner world. Ideas are NOT considered delusional in person’s culture o Odd beliefs, paranoid ideation, eccentric behaviour, ideas of reference o Eccentric recluse · Schizoid – pervasive pattern of social detachment and restricted range of emotional expression with other people o Does not desire or enjoy close relationships and prefers solitary activities o Detached affect, indifference to criticism or praise o Mad scientist · Paranoid – pervasive pattern of distrust and suspiciousness of other people o Not delusional, paranoia is pervasive o Unforgiving, suspicious of others, perceives attacks, everybody is enemy or friend, fear of confiding in others o Litigious fanatic § Cluster B – Bad – Histrionic, Borderline, Antisocial, Narcissistic · Overarching trait of being emotional or deficient in empathy accompanied by impulsivity · Histrionic – Pervasive pattern of excessive emotion and attention seeking, with shallow and rapidly shifting emotions o Provocative o Attention seeking o Easily Influenced o Exaggerated emotions o Drama Queen · Borderline- Pervasive pattern of unstable interpersonal relationships, self-image, affect and behaviour o Efforts to avoid real/imagined abandonment o Splitting – extremes of idealization and devaluation o Impulsivity o Difficulty with anger control o Self harmer · Antisocial – Pervasive pattern of disregard for the rights of others and rules (evidence of conduct disorder in childhood) o Impulsive, reckless, no remorse o Insufficient in planning, forensic hx, remorse lacking o Repeat offender · Narcissistic – Pervasive pattern of heightened sense of self-importance, need for admiration and lack of empathy o Arrogant, self-absorbed, entitled, exploitative o Fantasies of success o Envious o Arrogant o Lacks empathy, exploitative o Corporate climber § Cluster C – Sad – Avoidant, Dependent, Obsessive-compulsive Personality · Avoidant – Pervasive pattern of social inhibition, feeling of inadequacy and hypersensitivity to rejection (inferiority complex) o Desiring of company, too fearful of rejection to form relationships o Self-view of unappealing, inept, inferior o Shrinking violet · Dependent – Pervasive pattern of excessive need to be cared for and fear of separation – over-reliance on others o Subservient wife · Obsessive – Compulsive – Pervasive pattern of preoccupation with orderliness, perfectionism and control at expense of flexibility and efficiency o Excessive attention to rules, details and order, can’t delegate tasks o No similar recurrent obsessions to OCD o Control freak
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o What are the advantages and disadvantages of the dsm-5 classification of personality disorders?
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§ Advantages · 10 categories, 3 clusters, reliable § Disadvantages · Objective study of subjective phenomena · Some syndromes left out · Can have multiple personality disorders from different clusters
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o Alternatives to DSM for personality traits and disorder classification
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§ Psychodynamic theory § Cognitive theory § Attachment § Biological perspectives
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o What do you understand by the term psychopathy and what are its core features?
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§ Developmental disorder characterised by emotional deficits and incr. risk of antisocial disorder. Equiv. to antisocial personality disorder which focuses on behaviour and not cause. § Dysfunction in capacity to sympathise. No respect for authority or rights of others. § Reckless behaviour, inappropriate aggression, Pathological lying. § May have significant Forensic history
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o What are the core features of borderline personality disorder?
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§ Pervasive pattern of unstable interpersonal relationships, self image, affects and behaviour § Relationships marked with intense idealization or denigration of individuals (splitting) § Unstable and intense affects – impulsively acts out § Mood swings, affective dysregulation, anger, self-harm, substance abuse, depression, dissociative or transient psychotic features § Severe developmental trauma
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o Which psychiatric conditions are commonly comorbid with each type of personality disorder?
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§ Schizotypal · Depersonalisation · Anxiety · Depression · Schizophreniform disorders § Schizoid · Anxiety · Depression § Paranoid · Anxiety · Depression · Delusional disorders § Histrionic · Anxiety § Borderline · Anxiety · Suicidal ideation/ situational crisis · Depression § Depression § Anxiety § Depersonalization § Eating disorders § Brief Psychosis
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o What are the key principles of attachment theory? How is attachment theory useful in understanding of psychiatric presentations?
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§ Pattern of relationship § Self-protective strategy § Circle of security – needs of attachment figure change depending on exploration v7s security. Child needs attachment figure to predictably respond to childs needs – child needs to come and go with equal confidence § Types: · A – Avoidant · B – Secure and balanced · C – negative and unpredictable · D – no coherent strategy § Assists: · Psychiatric presentations of personality disorders – causative factors for personality disorder developemtn · Depressed mother
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o Describe Erikson’s stages of psychosocial development.
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§ Infancy - <18 mth · Trust vs mistrust § Early Childhood - <3 yrs · Autonomy vs shame and doubt § Kindergarten - <5 years · Initiative vs guilt § School age - <11 years · Industry vs inferiority § Adolescence - <18 years · Identity vs role confusion § Adult – Early · Intimacy vs isolation § Adult – Mid · Generativity vs stagnation § Adult – Late · Integrity vs despair
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o Describe the core domains of dysfunction in the DSM V diagnosis of Autism spectrum disorder
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§ Social – Persistent deficits in social communication and social interaction · Deficits in social-emotional reciprocity, failure of normal conversation, reduced sharing of interests, emotions or affect · Failure to respond to normal social interaction · Deficits in nonverbal communicative behaviours § Behaviour – restricted, repetitive patterns of behaviour, interests and activities · Repetitive motor movements · Insistence on sameness · Restricted and fixated interests, abnormal in intensity
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o Describe the core domains of dysfunction in Attention deficit/hyperactivity disorder
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§ Inattention · Easily distracted · Difficulty maintaining focus · Bored after a few minutes · Difficulty focusing attention · Not seem to listen · Difficulty processing information as quickly as others § Hyperactivity · Fidgety · Talk nonstop · Trouble sitting still · Constantly in motion § Impulsivity · Impatient · Blurt out inappropriate comments · Difficulty waiting § Impairment in social, academic or occupational environments
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o Discuss the differential diagnosis of attention deficit/hyperactivity disorder |
§ Developmental variations · Intellectual disability/giftedness § Neurological conditions · Language communication disorders · Autism spectrum disorders · Motor coordination disorders § Emotional and behavioural disorders · Anxiety disorders · Mood disorders · Oppositional defiant disorder · Conduct disorder · OCD · PTSD · Adjustment disorder § Psychosocial and environmental · Stressful home environment § Medical conditions · Hearing/visual impairment · Lead poisoning · Thyroid Pathology
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o In the clinical setting how would you differentiate between anxiety and an anxiety disorder?
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§ Anxiety –feeling of inner restlessness accompanied by dread of apprehension · Autonomic symptoms – sweating, trembling, tachycardia, palpitations, tightness in chest, abdo. Discomfort, restlessness § Pathological · Involves inappropriate response due to intensity of reaction or duration. · Overwhelming and out of proportion · Significant distress and impairment of function
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o Give a brief overview of the anxiety disorders as described in DSM-V
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§ Panic Attack · Discrete period in which sudden onset of o apprehension, o fearfulness or terror, associated with feelings of impending doom. o Physical symptoms § SoB, § palpitations, § tingling fingers, § chest pain, § smothering sensation present · Peak at 10 minutes, subside over next 30 minutes § Panic disorder · Recurrent unexpected panic attacks accompanied by 1 month of concern about another attack · Significant behavioural changes associated with avoiding attacks § Agoraphobia · Anxiety about/avoidance of environments that are perceived as dangerous or uncomfortable – open spaces + social situations · Avoidance of public places § Specific phobia · Irrational fear of objects, places, or situations · Anxiety provoked when exposed to triggers o Avoidance behaviour triggered § Social Phobia · Anxiety provoked by exposure to certain types of social situations leading to avoidance behaviour § Obsessive Compulsive Disorder · Obsessions or compulsions · Obsession - Recurrent persistent ideas, thoughts, impulses or images that are intrusive and distressing · Compulsions – repetitive and intentional behaviours performed in response to obsessions. § Post-traumatic stress disorder · Re-experiencing of extremely traumatic event accompanied by symptoms of increased arousal and avoidance of stimuli associated with trauma. · May include nightmares about event · Could be concurrent with dissociation with event and repression § Acute stress disorder · Symptoms similar to PTSD immediately after aftermath of traumatic event – emotional numbing, amnesia, intrusion, avoidance, hyperarousal § Generalised anxiety disorder · 6 months persistent anxiety and/or worry · Excessive worry about life circumstances – health, finances, social acceptance, job performance, etc. § Anxiety due to medical condition · Anxiety due to direct physiological consequence of medical condition e.g. hyperthyroidism, phaeochromocytoma § Substance induced anxiety · Prominent symptoms of anxiety brought on by drug of abuse, medication, toxin exposure § Anxiety disorder not specificed · Anxiety that doesn’t meet criteria for any categories
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o When would you diagnose a patient as suffering from a generalised anxiety disorder?
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§ Excessive worry about life circumstances – health, finances, social acceptance, job performance, martial adjustment § For at least 6 months § Causes clinically significant distress or impairment in social, occupational or other areas
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o What is the differential diagnosis of GAD?
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§ Drug induced – caffeine, stimulants, alcohol withdrawal, sedative withdrawal § Panic disorder § Social phobia § OCD § Anorexia § Specific phobias § PTSD
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o When would you diagnose a patient as suffering from a panic disorder?
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§ Recurrent unexpected panic attacks accompanied by 1 month persistent concern about having another attack § Can be accompanied by agoraphobia
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o When would you diagnose a patient as suffering from a post-traumatic stress disorder?
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§ Exposure from traumatic event in the past where the patient · Actual or threatened death, serious injury, or physical integrity to self or others · Accompanied by intense fear, helplessness or horror § Persistently re-experienced in: · Intrusive recollections of events · Recurring dreams of event · Feeling as if event is recurring · Psychological distress when exposed to internal/external cues similar to event § Avoidance of stimuli associated with event § Persistent symptoms of arousal · Difficulty falling/staying asleep · Irritability/outbursts of anger · Hypervigilance § Acute PTSD – Duration <3 months § Chronic PTSD – Duration >3 months
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o When would you diagnose a patient as suffering from a social phobia?
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§ Irrational fear of specific objects, places, or situations § Fear of humiliation of embarrassment in public places § Recognition that fear is excessive or unreasonable
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o What is the difference between agoraphobia and social phobia?
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§ Agoraphobia – Fear about places or situations where individual has little control, or escape may be difficult. May have component of embarrassment when triggered in public. · Open spaces, crowded places § Social Phobia – Fear of social or performance situations which person is exposed to scrutiny by others · Exposure provokes fear or anxiety out of proportion and persistent · Interferes with function
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o What is the difference between social phobia and an avoidant personality disorder?
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§ Social Phobia – persistent fear of social or performance situation § Avoidant personality disorder – CRINGES · Certainty of being disliked before relationship · Rejection possibility preoccupies thoughts · Intimate relationships avoided · Gets around occupational activities that involve interpersonal contact · Embarrassment potential · Self-viewed as unappealing, inept, inferior
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o When would you diagnose a patient as suffering from a specific phobia?
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§ Irrational fear of specific objects, places, or situations § Fear is irrational, excessive, disproportionate § Well circumscribed and involve situations that could possibly result in harm · Heights · Snakes · Flying · blood
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o What are the clinical features of a panic attack?
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§ Period of intense fear, developing abruptly, peaking <10 minutes and subsiding in 30 § Features (physical, agitation, psychological) · Palpitations · Sweating/chills · Trembling · Parasthesias · Nausea and abdominal distress · Feeling of choking · Shortness of breath · Dizziness · Derealisation · Fear of dying · Fear of losing control
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o What are the differential diagnoses of a panic attack?
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§ Anxiety disorder (PTSD, specific phobia, social phobia) § Psychosis, depression, mania § Cardiovascular conditions (cardiac arrhythmia) § Pulmonary conditions (asthma, pul. embolism) § Endocrine (phaeochromocytoma, Hypoglycaemia) § Substance abuse
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o How do you assess and manage panic attacks?
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§ Vitals – BSL, ECG, physical to exclude medical emergencies § Exclude psychosis § Find percipient if there is one § Management · Explain it’s a physiological process, can gain control of symptoms · Ask pt to focus on point and count while they breathe · Medical therapy – Lorazepam 1mg · Long term – education about symptom control, medications – e.g. SSRIs
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o When would you diagnose a patient as suffering from an obsessive compulsive disorder (OCD)?
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§ Intrusive and recurrent thoughts that causes marked anxiety and distress · May be accompanied by compulsive behaviour (behaviour performed in reaction to thoughts, may be unreasonable) to reduce symptoms § Patient recognises these thoughts are unreasonable and excessive
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o How is OCD different from Obsessive compulsive personality disorder (OCPD)?
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§ OCD – anxiety disorder in which obsessive thoughts are intrusive and unwanted, may be accompanied by compulsive behaviour § OCPD – personality disorder in which individual strives to be impractially perfectionistic and rigidly methodical. – Not accompanied by obsessive thoughts, but may have Preoccupations
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o In the clinical setting, how would you distinguish between a diagnosis of body dysmorphic disorder and delusional disorder with somatic features?
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§ Body dysmorphic disorder – Preoccupation with imagined bodily deficit that is severe enough to impair social or occupational functioning § Delusion disorder w/ somatic – possibly other non-bizarre delusions present, functioning is not markedly impaired
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o Give a brief overview of eating disorders as described in DSM-V
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§ Disturbance in eating behaviour § Anorexia nervosa – Refusal to maintain minimally normal body weight · May have binge-eating/purging type o Also have recurrent binge/purging, however unlike Bulimia, they do not want to maintain normal body weight § Bulimia nervosa – episodes of binge eating followed by inappropriate compensatory behaviour – induced vomiting, laxative misuse § Eating disorder not otherwise categorised – disorders that don’t fit into above 2 § Binge eating – episode of eating a significantly larger than normal meal accompanied by a sense of lack of control over eating episode § Purging – Compensatory behaviour in which individual takes laxatives or takes laxatives following an episode of binge eating
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o Discuss the subtypes of anorexia nervosa and the differences in their clinical implications
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§ Restricting type – no episodes of binge eating/purging in the last 3 months, however weight loss is done via dieting, fasting or excessive exercise § Binge/purge type – last 3 months individual has recurrent episodes of binge eating or purging accompanied with significant weight loss
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o How would you distinguish between the binging and purging type of anorexia nervosa and bulimia nervosa?
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§ Major distinguishing feature is intent to below normal weight range for an individual with anorexia nervosa |
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o What are the physical complications of anorexia nervosa?
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§ Amenorrhoea § Loss of bone density § Depressive symptoms, irritability, insomnia, loss of libido § Hypotension § Hypothermia § Bradycardia § Lanugo § Electrolyte disturbances – hypokalaemia, hypochloremic alkalosis § Elevated suicide risk § From vomiting: · Parotid hypertrophy · Dental enamel erosion · Oesophageal tears · Gastric rupture
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o What are the physical complications of bulimia nervosa?
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§ Amenorrhoea d.t. weight fluctuations/emotional distress § Purging – fluid and electrolyte disturbances § Dental damage § Oesophageal tears § Gastric rupture § Laxative dependency
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o What are the risk factors associated with eating disorders?
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§ Temperament – anxiety disorders or obsessional traits § Environmental – cultural influences, occupational influence § Troubled relationship with parents § Family history § Physical/sexual abuse
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o What do you understand by the term somatic symptom and related disorders as discussed in DSM-5? List and describe the specific disorders included in this category according to DSM-5
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§ Somatic symptom and related disorders – illness where bodily signs and symptoms are a major focus and symptoms are medically unexplained § Somatization disorder – multiple organ system involvement § Conversion disorder – neurological related (excl. pain) § Hypochondriasis – worried about being sick with a specific illness § Body dysmorphic disorder – dissatisfaction with body part/image § Persistent somatoform pain disorder – pain is main complaint § Undifferentiated somatoform disorder § Somatoform disorder Not otherwise specified
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o Hypochondriasis vs somatization
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§ Somatisation – Focus is on something wrong with the person and having multiple symptoms rather than specific disease – not intentionally feigned or produced · May have underlying personality disorders · Multisystem involvement § Hypochondriasis – Generalized non-delusional preoccupation with fears of having a specific illness, persists despite medical evaluation and reassurance · Lasts 6 months or more · Causes significant impairment
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o When would you diagnose conversion disorder, and how would you explain this condition to a patient that in your opinion may have this condition?
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§ Emotional distress manifesting physically § Neurological complaints · Motor symptoms · Sensory symptoms · Seizure § “sometimes when people are emotionally distressed, it manifests as physical symptoms” § Not intentionally feigned or produced § “your symptoms are not imaginary, however they are a result of emotional distress” § Treatment · Psychotherapy · Insight oriented behavioural therapy · Anxiolytics, behavioural relaxation exercises
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o Chronic pain vs somatoform pain disorder
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§ Somatoform pain disorder – preoccupation with pain in absence of physical disease to account for its severity § Chronic pain syndrome – ongoing pain for >3 months due to ongoing degenerative illness, neuropathic pain, hyperalgesia
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o What is the recognised approach to managing conversion disorder?
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§ Build a good relationship with the patient § Insight-oriented supportive or behaviour therapy § Hypnosis, anxiolytics, behavioural relaxation exercises § Psychodynamic psychotherapy § Benzodiazepine for anxiety and muscular tension § Antidepressants for obsessive ruminations
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o Describe the topographic theory of the mind as proposed by Freud?
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§ Topographic – conscious, preconscious, unconscious layers of an iceberg, structures of personality § Conscious – sensations and experiences individual is aware of § Preconscious – Between 2 levels, recallable memories, perceptions and thoughts individual is not consciously aware of § Unconscious – larger mind below surface incl. instincts, desires that direct behaviour
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o Describe the structural theory of the mind as proposed by Freud?
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§ 3 parts: · Id – basic instincts – present at birth, operates on pleasure principle · Ego – mediation of urges of Id and realities of external world, operates on reality principle · Super-ego – part of the ego of self-observation, self-criticism, judgemental faculties · Both ego and superego are both partially conscious and unconscious while Id is fully unconscious
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o What do you understand by the term ego defence mechanisms? List and give brief descriptions or examples of these (mature, neurotic, primitive)
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§ Ego defence mechanism – psychological mechanisms used to control reality § Mature · Humour – empathesizing amusing aspects of stressor · Sublimation – unacceptable feelings into socially acceptable behaviour – sports, hobbies · Suppression – avoiding thinking about problem until later § Neurotic · Displacement – transferring feelings to a substitute object · Dissociation – Temporary but drastic alteration of persons character to avoid emotional distress § Immature · Repression – Expelling disturbing thoughts from conscious awareness · Intellectualisation – detachment and generalization about events · Regression – returns to earlier phases of function to avoid current stressor · Splitting – inability to integrate positive and negative qualities of others, views individuals as polar opposites of all good or all bad § Primitive · Denial – Refusal to acknowledge current reality · Projection – false attribution of own unacceptable feelings onto another person
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o What do you understand by the terms transference and countertransference?
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§ Transference – Displacement of feelings for a significant person onto therapist § Countertransference – Redirect of therapist’s feelings toward a patient due to emotional entanglement
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o How can transference and countertransference affect the clinical practice of medicine?
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§ Short term – mediate immediate reactions during interview. May assist/harm rapport building depending on what feeling and how its managed § Long term – irrational kindness/concern causing difficulty in professional role, assists in exploring a patient’s inner mental state
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o Why is it important to try and understand the sociocultural background of a patient?
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§ Interventions must be acceptable by sufferer § May have assisted in the precipitation of individual’s psychiatric illness and presentation
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o How does counselling differ from psychotherapy?
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§ Counselling – focus is on assisting life issues, focused on problems vs personality § Psychotherapy – focus is on cognitive ideas, behavioural mechanisms and restructuring of personality
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o What are the fundamental principles of CBT and how and when would you use this therapeutic modality in the clinical setting?
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§ CBT – based on cognitive and behavioural theory to correct cognitive distortions and self-defeating behaviours. · Negative thoughts -> negative feelings -> negative actions § Focused on processes of thinking and reactions to events. § Approx. 15-20 visits § Used in: · Non-psychotic depression · Substance abuse
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o What are the fundamental principles of supportive psychotherapy, and how and when would you use this therapeutic modality in the clinical setting?
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§ Supportive psychotherapy – reinforcement of patient’s healthy and adaptive patterns of thought behaviour to reduce symptoms of psychological distress § Done through reassurance, guidance and a supportive environment for patient to ventilate feelings § Used in: · Emotionally/interpersonally disabled patients · Vulnerable and unable cope with daily needs.
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o Who are psychologists, and for what reasons might you refer a patient to a psychologist?
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§ Psychologist – individual train in study of behaviour and mental health § Referred for: · Psychotherapy · Cognitive assessment · Intellectual assessment · Developmental disorders
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o Discuss the use of psychotherapy in the treatment of major depressive disorder
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§ Supportive psychotherapy – improve self-esteem, psychological functioning, adaptive skills, useful during episodes with severe symptoms § Cognitive behavioural therapy – useful for dealing with repeated episodes by changing behaviours and is effective in the long run
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o Discuss the use of psychotherapy in the treatment of anxiety disorder
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§ Cognitive behavioural therapy – effective in treatment of anxiety by recognising and dealing with triggers for anxiety as well as impairments to relaxation |
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o Discuss the various domains of function in daily life and comment on how mental illness may impact on these domains of function
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§ Self-Care – decreases with depression, schizophrenia, mania § Financial – may have impulsivity in manic episodes, affected by paranoid, psychosis etc. § Carer responsibilities – children or others in patient’s care – affected in depression, mania, paranoid psychosis, suicidality § Occupational/educational – may neglect work/education in depression, mania, personality disorders may affect work e.g. obsessive compulsive personality disorder § Social – social isolation may occur and/or precipitate depression, odd behaviour d.t. schizophreniform disorders may concern or frighten others
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o How does impaired function contribute to relapse in mental illness?
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§ May lead to: · Poor compliance to medications · Social isolation · Decreased motivation and responsibilities, leading to exacerbation of depression
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o Who are OT and for what reasons might you refer a patient to an OT?
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§ OT – individuals trained to assess and assist patients in activities of daily living · Self-care, household, community involvement, work/study, leisure activities § Necessary for: · Assessment of ADLs, · Extent of need for additional aids · Suitability for independent living
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o Who are social workers and for what reasons might you refer a patient to a social worker?
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§ Social workers – individuals trained in counselling and support for individuals with difficult personal, social and/or family issues § Assists in working out options of care and referring individuals to appropriate government and community services § Necessary for: · Management of social/legal/financial well-being · E.g. individual needing assistance getting on a unemployment pension or accommodation
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o Why is it important to assess the social support network of a patient?
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§ Social support network necessary for normal daily functioning · Assists in reducing stress levels · Base human need · Easier for individuals with good networks to recover from illness § Key individuals – friends/family, community – key worker, community health teams, GP etc. § Also provide some form of monitoring for symptoms of relapse and accountability in terms of treatment – e.g. medication adherence
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o Substance withdrawal § What are the principles of managing alcohol withdrawal and how does the management differ if delirium tremens is present?
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· Assess –alcohol withdrawal level o Minor – 6-24 hrs after last drink § Tremor § Anxiety § Nausea § Vomiting § insomnia o Major – 10-24 hrs after last drink § Visual,auditory,tactile hallucinations § Whole body tremor § Vomiting § Diaphoresis § hypertension o Withdrawal Seizures – 6-48 hrs after last drink § Generalized brief seizures § Spontaneous resolution o Delirium tremens – 3-10 days after last drink § Agitation § Global confusion § Disorientation § Hallucinations § Hypertension § Fever § Diaphoresis § Autonomic hyperactivity · Assess – wernickes encephalopathy o Level of hydration for thiamine thirst o Thiamine administration 200mg parental, then 100mg daily · Alcohol withdrawal observation chart for changes · Treatment for uncomplicated withdrawal o Diazepam 10-20mg to cover agitation · Delirium tremens: onset 3 days after last drink o Safety to patient and staff o Diazepam for decreasing symptom severity o Antiepileptics for withdrawal seizures o Antipsychotics – severe agitation or halucinations – haloperidol is less likely to reduce seizure threshold (other have decr. Seizure threshold)
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§ What medications can be used as an adjunct therapy in alcohol dependence?
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· Disulfiram – blocks aldehyde dehydrogenase – accumulation of acetaldehyde when drinking – tachycardia, vomiting, palpitations, arrhythmias, seizures · Naltrexone – opioid antagonist – decr. High from alcohol, no cravings · Acamprosate – unclear mechanism, affects Glutamate and GABA, decreases craving for alcohol
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o Nicotine dependence – Smoking cessation what pharmacotherapies are available?
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· Nicotine replacement therapy - patches, inhaler · Vareniciline – Nicotinic agonist – reduces craving for nicotine · Buproprion – norepinephrine dopamine reuptake inhibitor
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§ What are the indications for antipsychotic treatment?
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· Acute and chronic psychosis · Anxiety and agitation · Bipolar · Mania · Delirium · Alcoholic hallucinosis
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§ What are the different classes of antipsychotic drugs? What are common side effects? What are serious but uncommon side effects?
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· Typical – Blocks D2 receptors indiscriminately, treats positive symptoms o Examples § Haloperidol – high potency · Prolonged QT · Hyperprolactinemia · (less sedating, less anticholinergic) § Chlorpromazine low potency · Metabolic syndrome · Anticholinergic, sedative · Orthostatic hypotension · Photosensitivity · (less EPS) § Flupenthixol - depot · hyperglycaemia § Zuclopenthixol acetate – more sedating than benzos, 48 hrs duration depot o Side effects § More associated with Extrapyramidal side effects · Irreversible Tardative dyskinesia § Weight gain § Sedating o Precautions § Parkinson’s – may aggrevate § Epilepsy – lowers seizure threshold § Hyperthyroidism – incr. risk of acute dystonia · Atypical – Blocks D2 receptors less selectively, 5HT receptors, D1 receptors, treats both positive and negative symptoms o Examples § Olanzapine · Weight gain · Metabolic syndrome · Hyperglycaemia · Dyslipidaemia § Risperidone (paliperidone is secondary metabolite, used in depos of 28 day durations) · Sedation · Weight gain · Orthostatic hypotension · Tachycardia · Paradoxical anxiety and agitation § Quetiapine § Amisulpride § Aripipazole
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o What is rehabilitation? When and how would you use this approach in the clinical setting?
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§ Rehabilitation – therapy aimed at assisting restoration of mental health and life skills after mental illness – includes step down facilities to ensure patient is not overwhelmed after discharge § Necessary after individual has recovered from an illness e.g. major depressive episode
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§ What is clozapine? Who would you prescribe this to? What are its side effects and monitoring requirements?
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· Clonzepine – atypical antipsychotic o Indication – treatment resistant schizophrenic patients – 2 groups of antipsychotic treatment resistance § Highly effective w/ minimal risk of EPS § o MoA – Blocks D1 and D2 receptors o Side effects § Agranulocytosis § Seizures § Myocarditis § Orthostatic hypotension § Sedation § Weight gain § Anti-cholinergic side effects § Dyslipidaemia o Monitoring § Baseline · Weight · BGL · BP · Lipids § Ongoing · CBE · BGL + lipids · Troponin · Echo · ECG
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§ Describe the neuroleptic malignant syndrome, its clinical features and its significance
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· Neuroleptic malignant syndrome - rare, possibly fatal syndrome caused by abrupt loss of dopaminergic tone · Features – FARM - develops in 72 hours o Fever o Autonomic changes (Tachycardia, labile BP, sweating) o Rigidity, tremor o Mental status changes – confusion, delirium · Significance o Acute kidney failure o Rhabdomyolysis · Not dose dependent · Treat with hydration, cooling blankets
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§ What assessment and monitoring approaches should be adopted for metabolic risks associated with atypical antipsychotic use?
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· Metabolic syndrome – constellation of metabolic abnormalities that cause incr. risk of CVD and DM o Central obesity o Hypertriglyceridemia o Low HDL cholesterol o Hyperglycaemia o Hypertension · Atypical – higher chance · Monitoring – Weight, BP, Cholesterol profile, BGL
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§ What are the extrapyramidal side effects associated with antipsychotics? How do you recognise each of these in a clinical setting and how would you manage them?
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· Dystonia – Abnormal posture, torsions, muscle spasms o Treat with lorazepam · Akathesia – motor restlessness o Treat with lorazepam · Pseudoparkinsonism – rigidity, tremor, akinesia o Treat with lorazepam · Dyskinesia – repetitive constant movements o No treatment
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§ What are the different types of antidepressants? What are their side effects? How would you select which antidepressant to prescribe for a particular patient?
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· MAOI – Monoamine oxidase inhibitors o Examples – Phenelzine, Moclobemide, Buspirone o Side effects – Hypertension, anticholinergic effects, weight gain, sleep disturbances, headache · TCA – Tricyclic antidepressants o Older generation, not used as often, can OD, lots of side effects o MOA – inhibition of reuptake of noradrenaline, serotonin, o Examples – Amyltriptyline, Imipramine o Side effects – orthostatic hypotension, drowsiness, blurred vision, dry mouth, Sedation, weight gain, anticholinergic effects o Contraindicated – treatment with MAOI, · SSRI – Selective serotonin reuptake inhibitors – risk of serotonin syndrome o First line in treatment of depressive and anxiety disorders, not likely to die from OD o Examples – § Sertraline – Least chance of side effects § Paroxetine – most efficacy, shortest half-life, greatest withdrawal § Fluoxetine – Longest half-life, least withdrawal chance § Citalopram, escitalopram o Side effects – sexual dysfunction, withdrawal symptoms, nausea, diarrhoea, insomnia, agitation · SNRI – Serotonin noradrenaline reuptake inhibitors o May have higher efficacy compared to SSRIs o Examples – Venlafaxine (+ desvenlafaxine), Duloxetine o Side effects – Rash, Nausea, Constipation, Sexual dysfunction, insomnia, sedation o Contraindicated – treatment with MAOI, · SDRI – Serotonin and dopamine reuptake inhibitors o Examples – Buproprion o Side effects – Dry mouth, nausea, sweating, insomnia
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§ What are the major drug interactions and adverse effects to be concerned about when using a monoamine oxidase inhibitor (MAOI)?
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· Serotonin toxicity - Cocaine, SNRIs, SSRIs, TCAs, Dextromethorphan, fentanyl, methylphenidate, pseudoepehedrine · Hypertensive crisis – Foods containing tyramine – Mature cheese, fermented products, protein extracts
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§ What are the major drug interactions to be concerned about when using a selective serotonin reuptake inhibitor (SSRI)?
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· Serotonin toxicity – MAOI · Lowers seizure threshold – do not mix with antipsychotics · P450 enzyme inhibitor – phenyltoin, carbamezapine, diazepam
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§ Describe the serotonin syndrome, its clinical features and its significance.
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· Serotonin syndrome – excess serotonin in CNS, SSRI or MAOI causes o Diarrhoea o Restlessness o Agitation o Hypereflexia o Seizures o Myoclonus o Hyperthermia o Delirium
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§ What are the different classes of mood stabilising agents? What are the side effects?
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· Lithium – Type 1 bipolar – unknown MoA o Side effects – thirst, polyuria, metallic taste, diarrhoea, weight gain, lithium toxicity – blurred vision, GI upset, o Monitoring – Renal excretion, thyroid function, nephrogenic DI · Anticonvulsants – Sodium valproate, carbamazepine, lamotrigine o Valproate – Teratogen, Headache, thrombocytopenia, rise in LFTs o Carbamazepine – sedation, bone marrow suppression, rash, sedation, stevens-johnson syndrome o Lifelong maintenance may be needed · Antipsychotics – olanzapine, quietapine o Side effects – sedation, QT interval prolongation, metabolic dysfunction
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§ How would you prevent, recognise and manage lithium toxicity in the clinical setting?
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· Prevention – regular monitoring of blood lithium levels, toxicity may occur at higher concentrations o Renal impairment, Fluid loss – dehydration or exercise · Assessment: o GIT – Severe N/V + diarrhoea o Cerebellar – Ataxia, slurred speech, incoordination o Cerebral – Myoclonus, parkinsonian movements, seizures · Management o Supportive therapy § Prevention of aspiration, benzos for seizures o Gastric lavage – if within 1 hour o Elimination – fluid therapy
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§ What are the major drug interactions to be concerned about when using lithium?
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· Nephrotoxicity – ACEi, loop diuretics, NSAIDs · Serotonin toxicity – SSRIs, MAOIs
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§ Discuss the indications for and safe use of benzodiazepines.
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· Indication o Anxiety and depression o Sedation o Anti-convulsant effect · Contraindications + safe use o Limited usage duration with slow taper o Alcohol intoxication o Overdose considerations with other drugs · Mechanism of action – GABA receptor stimulation
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§ How are the individual benzodiazepines different from one another? How do you select which to prescribe?
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· Metabolism, duration, strength of effect · Midazolam – Short acting (2 hrs) · Lorazepam – Short acting (~8 hrs) · Alprazolam – Medium acting (24 hours) · Diazepam – Long acting (60 hours + longer for secondary metabolites), need to check liver function as secondaries are done through liver
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§ What are the side effects of benzodiazepines?
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· CNS depression – drowsiness, reduced motor coordination, memory impairment · Physical dependence + tolerance · Paradoxical excitation in some people
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§ Discuss the indications for and safe use of psychostimulants
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· Indication – ADHD, narcolepsy o Dexamphetamine and methylphenidate (Ritalin) · Safe use o Initiated at low dosage, titrated up slowly o Potential for abuse o Contraindicated in psychosis, worsen cardiac conditions
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§ What are the side effects of psychostimulants
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· Insomnia, irritability, paradoxical worsening · Tachycardia · Headache · Palpitations
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§ Discuss the indications for and safe use of medications used to treat dementia of the Alzheimer type.
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· Dementia – chronic global loss of cognitive and executive function, sparing of consciousness · Meds – NMDA antagonist – Memantine, Acetylcholinesterase inhibitors – Donepezil, Rivastigmine
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§ What are the side effects of the medications used to treat dementia of the Alzheimer type
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· Acetylcholinesterase inhibitors – SLUDGEMC o Salivation o Lacrimation o Urination o Defecation o Gastrointestinal motility o Emesis o Miosis o Cardiac (bradycardia) · NMDA antagonists – confusion, drowsiness, headache, hallucinations
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§ What is ECT, indications, side effects, procedure
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· Electoconvulsive therapy – electric current applied across scalp to induce grand-mal seizure, MoA unknown · Indications - Mood disorders o Treatment resistant depression or high suicide risk depression o Mania – Treatment resistant or acute · Side effects o Anaesthesia risks o Temporary memory loss o Muscle aches o May induce arrhythmias – ECG monitored before, during, after treatments · Procedure of ECT o Millicoulombs of charge delivered to brain – until seizure threshold is reached o Total number of treatments depends on severity o Lead placements § Unilateral – Usual treatment modality § Bifrontal – low response § Bitemporal – high response
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§ What is Transcranial magnetic stimulation (TMS)
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· Transcranial Magnetic Stimulation – Causes neuronal depolarisation/hyperpolarisation through weak electromagnetic induction from a rapidly changing magnetic field · Indicated in: o Major depressive disorder
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o What are the criteria for detention under the south Australian mental health act 2009?
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§ Has to be: · Suffering from mental illness · Because of illness, patient requires treatment for own protection from harm or protection of others from harm o Facilities are available for treatment of the patient · No less restrictive means of treatment other than an inpatient treatment order
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o What are the potential benefits and harms of detaining a patient under the mental health act?
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§ Benefits · Receive required treatment · Decrease in risk · Increased potential for rehabilitation § Harms · Agitation · Distrust of mental health services · Damaged therapeutic relationship · Perceived loss of control
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o What is the difference between an inpatient treatment order and a community treatment order?
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§ Inpatient treatment orders (ITOs) are to be carried out inside a mental health institution · Level 1 – 7 days o Made by psychiatrist or medical practitioners o Reviewed within 24 hours by psychiatrist, can be revoked at any time o Appeals can be made to guardianship board · Level 2 – 42 days o Made by psychiatrist or medical practitioner before expiry of level 1 o Varied or revoked at any time o Appeals can be made to guardianship board · Level 3 – 12 months (6 for child) o Only be made by guardianship board after application o Reviewed in 3 months if order was about a child § Community treatment orders (CTOs) are mandatory treatments to be carried out in the community e.g. drug depos, therapy · Level 1 – 28 days o Made by psychiatrist or medical practitioner o Review within 24 hours by psychiatrist o Guardianship board must review within 28 days o Appeals can be made to guardianship board · Level 2 – 12 months (6 for child) o Only made by guardianship board after application o Reviewed in 3 months if order was about a child o Appeals to district court |
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o What do you understand by the term mental capacity?
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§ Ability to make reasoned decisions autonomously · Decision specific · Time and circumstance specific · Independent of actual decision made · Free from undue influence
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o What are the criteria to be considered when applying for a guardianship order?
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§ No less restrictive means available § Patient must be deemed to be incapable mentally to decide · Impairment of mental functioning or basic communication AND · Impairment is sufficient to affect ability to make specific decision
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o What legal powers can the guardianship board of South Australia grand to a legal guardian to look after the interests of a protected person?
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§ Guardianship Order – Guardianship board can appoint guardian to make lifestyle and medical treatment decisions for person without mental capacity § Patient under guardianship order – Protected person § Limited guardianship order – limited to particular aspects of patient’s care § Legal guardian of protected person: · No obligation to care for daily needs · Has an obligation to approve care and management plans § Legal guardians are – family member or friend, Public advocate
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o When would you consider asking guardianship board of South Australia to appoint an administrator to look after financial affairs of an individual?
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§ Patient does not have mental capacity § Cannot make reasonable decisions because of incapacity § Decisions need to be made and there is no less restrictive way of making it § Assist to improve quality of life
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o Discuss the mandatory notifications that are required of doctors practising in South Australia.
|
§ Suspects on reasonable grounds that a child is being abused/neglected including: · Physical abuse · Sexual abuse · Emotional/psychological abuse · Neglect
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o How is Mental incompetence judged if charged with felony
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§ Suffering from a mental impairment, and consequentially: · Did not know nature and quality of conduct · Did not know conduct was wrong · Was unable to control conduct
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