1. Past Papers Flashcards

Question

In the side effect profile of 1st generation anti-psychotics, what are the anticholinergic side effects?

Answer 1

Anticholinergic side effects: - **dry** **mouth** - **blurred** **vision** - glaucoma - **dysuria** - urinary **retention** - constipation - ileus

Answer 2

postural **hypotension**, **sexual** dysfunction

Answer 3

Anti-histamininc: **sedation** and **weight** gain

Answer 4

EPSEs Anticholinergic Antiadrenergic Antihistaminic Other side effects

Answer 5

1. Determine whether they're high or low **risk** by looking at the risk **factors**: Look at risk factors: **SADPERSONS** *5-6: medium risk,* 7 or more: high risk ● S: Male **sex** ● A: **Age** (<19 or >45 years) ● D: **Depression** ● P: Previous attempt ● E: Excess **alcohol** or substance use ● R: **Rational** thinking loss ● S: **Social** supports lacking ● O: Organized **plan** ● N: No **spouse** ● S: **Sickness** (GMC) + general risk factors (family history, non-compliance, feelings of hopelessness, unemployment) 2. Then determine **ideation**, intention, plan - **ideation**: **content** and **duration** of thoughts - **intention**: **self-harm** vs suicide - **plan**: **detail**, **lethality**, concealment and **preparation** 3. Then **examine** and **assess** them ● Assessment steps: o Ensure **physical** condition is **stabilised** o Physical **examination** for **medical** **illness**/drug intoxication o **Collateral** interviews from family, colleagues, friends o Psych exam: Hx, **MSE** o Current **presentation of suicidality: lethality** of method, level of intent, steps enacted, feelings of hopelessness o **Psychiatric** illness and **history** thereof o History of **previous** suicide **attempts** o **Psychosocial** situation o Individual **strength** and **vulnerabilities** – **coping** mechanisms, **personality** traits, past response to **stressors** 4. Then do a **post assessment** ● Post-assessment: Likely **risk** of further self-harm, is there a **treatable** mental illness, **psychosocial** problems that need to be addressed, **intervention** and support required to reduce risk 5. Look out for the **warning signs **of suicide = o **Talk**: self-criticism, talking about killing themselves, joke about suicide, having no reason to live, being a burden to others, feeling trapped o **Behaviour**: increased substance use, looking for a way to kill themselves, reckless, *change* in *personality*, *withdrawal* from activities, loss of interest in appearance, *sleeping* too much/too little, calling people to say bye, preparing for death by *giving away* possessions o **Mood**: depression,* loss of interest*, *rage*, irritability, humiliation, anxiety, excessive feelings of guilt

Answer 6

5. Look out for the warning signs of suicide = o **TALK**: self-**criticism**, talking about **killing** themselves, **joke** about suicide, having no reason to live, being a **burden** to others, feeling **trapped** o **BEHAVIOUR**: increased **substance** use, looking for a **way** to kill themselves, **reckless**, change in **personality**, **withdrawal** from activities, loss of interest in **appearance**, **sleeping** too much/too little, calling people to say bye, preparing for death by giving away **possessions** o MOOD: **depression**, loss of **interest**, **rage**, **irritability**, humiliation, **anxiety**, excessive feelings of guilt

Answer 7

1. Determine whether they're high or low risk by looking at the risk factors: Look at risk factors: SADPERSONS 5-6: medium risk, 7 or more: high risk ● S: Male **sex** ● A: **Age** (<19 or >45 years) ● D: **Depression** ● P: Previous **attempt** ● E: Excess **alcohol** or substance use ● R: Rational **thinking** loss ● S: Social **supports** lacking ● O: Organized **plan** ● N: No **spouse** ● S: **Sickness** (GMC) + general risk factors (family history, non-compliance, feelings of hopelessness, unemployment)

Answer 8

**Ideation** **Intention** **Plan** - ideation: **content** and duration of thoughts - intention: **self-harm** vs suicide - plan: **detail**, **lethality**, concealment and **preparation**

Answer 9

4. ● Assessment steps: o Ensure **physical** condition is **stabilised** o Physical **examination** for **medical** illness/drug intoxication o **Collateral** interviews from family, colleagues, friends o Psych exam: Hx, **MSE** o Current **presentation of suicidality: lethality** of method, level of **intent**, steps enacted, feelings of **hopelessness** o **Psychiatric** illness and **history** thereof o History of **previous** suicide **attempts** o **Psychosocial** situation o Individual **strength** and **vulnerabilities** – **coping** mechanisms, **personality** traits, past response to stressors

Answer 10

Post-assessment: Likely **risk** of further self-harm, is there a **treatable** mental illness, **psychosocial** problems that need to be addressed, **intervention** and **support** required to reduce risk

Answer 11

● Presence of Severe **psychological** **disturbance** following a **traumatic** event characterised by **involuntary** **re-experiencing** of elements of the event with symptoms of **hyperarousal**, **avoidance** and emotional numbing ● Symptoms and signs: o **Within 6 MONTHS** of traumatic event, **present** for at least **1 month **with clinically significant **distress** or **impairment** in social, occupational or other important areas of **functioning** o **EXPOSURE**: **directly** **experiencing**, witnessing, events happening to close person, **repeated**/extreme **exposure** to details of traumatic events o **ONE OR MORE:** **recurrent**/intrusive **memories** of event, recurrent **dreams**, **dissociative** **reactions** where it feels **like events** are **recurring**, **intense**/prolonged **distress** to **cues** that symbolise/resemble event o **AVOIDANCE** OF STIMULI associated with event – efforts to **avoid** distressing **memories** or **external** **reminders** of those distressing memories o **NEGATIVE** **ALTERATIONS** in cognition and **mood** – **inability** to **remember** aspects, **negative** **beliefs** about **oneself**, **distorted** **cognition** about cause and **consequence** of **event**, **negative** **emotional** state, **diminished** **interest** in activities, **detachment**/estrangement from others, **inability** to experience **positive** **emotions** o **INCREASED** **PHYSIOLOGICAL** SENSITIVITY and arousal: **sleep** disturbance, **irritability** or **outbursts** of anger, difficulty **concentrating**, **hypervigilance**, **exaggerated startle response**, reckless/**self-destructive**

Answer 12

● Symptoms and signs: o Within **6 MONTHS of** traumatic **event**, present for **at least 1 month** with clinically significant **distress** or **impairment** in social, occupational or other important areas of **functioning** o **EXPOSURE**: **directly** **experiencing**, witnessing, events happening to close person, **repeated**/extreme **exposure** to details of traumatic events o **ONE OR MORE**: **recurrent**/intrusive **memories** of event, recurrent **dreams**, **dissociative** **reactions** where it feels like events are recurring, **intense**/prolonged **distress** to **cues** that symbolise/resemble event o **AVOIDANCE OF STIMULI** associated with event – efforts to **avoid** distressing **memories** **or **external **reminders** of those distressing memories o **NEGATIVE ALTERATIONS** in cognition and mood – **inability to remember** aspects, **negative** beliefs about **oneself**, **distorted** **cognition** about cause and **consequence** of event, **negative** **emotional** state, **diminished** **interest** in activities, **detachment**/estrangement from **others**, **inability** to experience **positive** **emotions** o **INCREASED PHYSIOLOGICAL SENSITIVITY** and arousal: **sleep** disturbance, **irritability** or outbursts of **anger**, difficulty **concentrating**, **hypervigilance**, exaggerated startle response, reckless/self-destructive

Answer 13

Severe **psychological** **disturbance** **following** a **traumatic** event **characterised** by **involuntary** **re**-**experiencing** of elements of the event with **symptoms** of **hyperarousal**, **avoidance** and emotional **numbing**

Answer 14

● Mnemonic –** AM SUICIDE** need 5: - **abandonment** - mood **instability** [unpredictable affect/labile] - **unstable** and intense relationships - **suicidal** behaviour/self-harm - **impulsivity** - **control** of **anger** is **poor** - identity disturbance [**unclear** **identity**] - **dissociative** symptoms - **emptiness**

Answer 15

● Mnemonic –** AM SUICIDE** need 5: - **abandonment** - mood **instability** [unpredictable affect/labile] - **unstable** and intense relationships - **suicidal** behaviour/self-harm - **impulsivity** - **control** of **anger** is **poor** - identity disturbance [**unclear** **identity**] - **dissociative** symptoms - **emptiness**

Answer 16

Delirium/ Dementia 1. **Onset**: *Acute* [hours to days] Gradual // step-wise decline 2. **Duration**: *Days to weeks* // Months to years 3. **Course**: *Fluctuating* // Progressive 4. **Level** **OC**: *Clouded, fluctuating *// Alert 5. **Orientation**: *Impaired* // Initially intact, impaired later 6. **Attention**: *Decreased* // Not initially affected 7. **Sleep**: *Reversal of sleep wake cycle* // Occasional night-time confusion 8. **Restlessness**: *Worse at night* // Worse in the day 9. **Psychomotor** **activity**: *Agitated or slowed* // Initially unchanged, impaired later 10. **Mood** and **affect**: *Anxious, irritable, fluctuating *// Labile but not anxious 11. **Perceptions**: *Visual hallucinations *//Variable 12. **Reversibility**: *Reversible* // Irreversible

Answer 17

Delirium/ Dementia 1. **Onset**: *Acute* [hours to days] Gradual // step-wise decline 2. **Duration**: *Days to weeks* // Months to years 3. **Course**: *Fluctuating* // Progressive 4. **Level** **OC**: *Clouded, fluctuating *// Alert 5. **Orientation**: *Impaired* // Initially intact, impaired later 6. **Attention**: *Decreased* // Not initially affected 7. **Sleep**: *Reversal of sleep wake cycle* // Occasional night-time confusion 8. **Restlessness**: *Worse at night* // Worse in the day 9. **Psychomotor** **activity**: *Agitated or slowed* // Initially unchanged, impaired later 10. **Mood** and **affect**: *Anxious, irritable, fluctuating *// Labile but not anxious 11. **Perceptions**: *Visual hallucinations *//Variable 12. **Reversibility**: *Reversible* // Irreversible

Answer 18

Delirium/ Dementia 1. Onset: 2. Duration: 3. Course: 4. Level OC: 5. Orientation: 6. Attention: 7. Sleep: 8. Restlessness: 9. Psychomotor activity: 10. Mood and affect: 11. Perceptions: 12. Reversibility: DOC LOA SRP MRP

Answer 19

● Majority can be managed in **primary** **care** or by **specialist** **enuresis** **clinics**, referral to **psychiatry** only when there is wider disturbance of **emotions** and behaviour ● Careful **assessment** – includes thorough medical **history** and **examination** with **investigations** ● **Psychoeducation** of child and parents on **diagnosis** and **treatment** options ● Treat **organic** causes: **structural** abnormalities or **infection** of the Genito-urinary tract ● **Urotherapy**: **increase** bladder **capacity**, **decrease** **night**-time **urine** output, sensitise to unconsciousness awareness of bladder filling o **Techniques**: daily increase in fluid intake, **reduced** **nightly** **intake**, **regular** bladder **emptying**, **pre**-**bedtime** **voiding**, daily bowel action, **avoid** **caffeine** and high **sugar** containing drinks o **Information**, instruction, **life**-**style** advice, registration of symptoms and voiding habits, **support** with the caregiver o **Biofeedback**: pelvic floor **muscle** retraining o **Alarm** therapy: device that gives acoustic signal after episode of incontinence. Bell and Pad method o **Reward** systems [**star**-charts] ● **Medication**: **desmopressin**, **imipramine**, **oxybutynin**

Answer 20

o **Techniques**: daily increase in fluid intake, **reduced** **nightly** **intake**, **regular** bladder **emptying**, **pre**-**bedtime** **voiding**, daily bowel action, **avoid** **caffeine** and high **sugar** containing drinks o **Information**, instruction, life-style advice, registration of symptoms and voiding habits, support with the caregiver o **Biofeedback**: pelvic floor muscle retraining o **Alarm** therapy: device that gives acoustic signal after episode of incontinence. Bell and Pad method o **Reward** systems [star-charts]

Answer 21

Medication: **desmopressin**, **imipramine**, **oxybutynin**

Answer 22

Urotherapy: increase **bladder** **capacity**, **decrease** **night**-time **urine** output, **sensitise** to **unconsciousness** awareness of bladder **filling**

Answer 23

Definition: A **rare**, life-threatening **reaction** to **anti**-**psychotic** and other medication characterised by **fever**, muscular **rigidity**, altered **mental** status and **autonomic** dysfunction Symptoms/ signs: **hyperthermia** >38, muscular **rigidity**, **confusion**/agitation/**altered** **LOC**, **tachycardia**, **tachypnoea**, hyper/**hypotension**, diaphoresis, tremor, **incontinence**/retention/obstruction, creatinine kinase/urinary myoglobin, **leukocytosis**, **metabolic** **acidosis** Management: o **Benzos** for acute **behavioural** disturbance [restraint and IM may alter CK levels] o **Stop** any possible **causative** agents [anti-psychotics] and restart anti-Parkinsonian symptoms o **Supportive**: oxygen, **correct** hypotension with **fluids**, reduce **temp** with **cooling** blankets/**anti-pyretics**/cooled IVI fluids/ice packs/ice-water enema o **Rhabdomyolysis**: vigorous **hydration** and alkalinisation of urine using IVI **sodium** **bicarbonate** to **prevent** renal **failure** o **Pharmacotherapy** to reduce **rigidity**: **Dantrolene** 0.8-2.5mg/kg IV qds, up to 500mg **Lorazepam**, 2nd line bromocriptine or amantadine, 3rd line **Nifedipine**, consider **ECT** o **Follow** **up**: **monitor** closely, once settled **allow 2+ weeks** before restarting **medication** [use low dose/low- potency/**atypicals**] and consider **prophylactic** **bromocriptine**

Answer 24

A **rare**, **life**-**threatening** reaction to anti-psychotic and other medication characterised by **fever**, muscular **rigidity**, altered **mental** status and **autonomic** dysfunction

Answer 25

- hyperthermia >38 ~ - muscular rigidity ~ - confusion/agitation/altered LOC ~ - tachycardia - tachypnoea - hyper/hypotension - diaphoresis, tremor, incontinence/retention/obstruction ~ - creatinine kinase/urinary myoglobin - leukocytosis - metabolic acidosis

Answer 26

o **Benzos** for acute behavioural disturbance [restraint and IM may alter CK levels] o **Stop** any possible **causative** agents [anti-psychotics] and restart anti-Parkinsonian symptoms o **Supportive**: **oxygen**, correct hypotension with **fluids**, reduce temp with cooling blankets/**anti**-**pyretics**/cooled IVI fluids/ice packs/ice-water enema o **Rhabdomyolysis**: vigorous hydration and alkalinisation of urine using IVI **sodium** **bicarbonate** to prevent renal failure o **Pharmacotherapy** to reduce **rigidity**: **Dantrolene** 0.8-2.5mg/kg IV qds, up to 500mg **Lorazepam**, 2nd line bromocriptine or amantadine, 3rd line **Nifedipine**, consider ECT o **Follow** **up**: **monitor** closely, once settled allow **2+ weeks** before restarting **medication** [use low dose/low- potency/**atypicals**] and consider prophylactic bromocriptine

Answer 27

o **Pharmacotherapy** to reduce rigidity: - **Dantrolene** 0.8-2.5mg/kg IV qds - up to 500mg **Lorazepam** - 2nd line **bromocriptine** or amantadine, - 3rd line **Nifedipine** - consider **ECT**

Answer 28

● **Independent**, partially **JUDICIAL** BODIES that derive **authority** from the **Mental** **Healthcare** **Act** ● Functions: - **considering** **appeals** against decisions of head of health establishment, - making **decisions** with regards to assisted and **involuntary** care, treatment and rehab **services**, - considering reviews and making **decisions** on **transfer** of patient to **max** **security** facilities - periodic reports of the mental health status of mentally ill prisoners ● Ensure **STEPS FOLLOWED **according to **MHCA** ● Provide **LEGAL ASSISTANCE** to patient if requested ● **CHECKS FORMS** completed correctly: ensure legitimacy of process and accuracy of forms (they have to **fill in a form 13** to say that the hospital does have grounds to do the 72 hour assessment and hold the patient during this time) ● Ensure no one is **DETAINED ERRONEOUSLY** ● **ENSURE PROCEDURES** are followed ● **REVIEWS CASE** if patient sends **form 15 (for an appeal)**; MHCB needs to give notice of receiving application within 7 days and see patient within 30 days Members: o **Mental** healthcare **practitioner**: **medical** practitioner, **psychiatrist**, psych **nurse**, **psychologist**, **OT**, **social** **worker** o Legal: **magistrate**, attorney or advocate o **Community** member: good understanding of mental health and referral systems in SA

Answer 29

Members: o **Mental** healthcare **practitioner**: **medical** **practitioner**, **psychiatrist**, psych **nurse**, **psychologist**, **OT**, **social worker** o **Legal**: **magistrate**, attorney or advocate o **Community** member: good understanding of mental health and referral systems in SA

Answer 30

Head and neck - headache, - dry mouth - excessive sweating [diaphoresis] GIT - Nausea and GI upset [diarrhoea], Vibes - restlessness/agitation/nervousness, - insomnia, - rash, - anxiety, - weight gain, - sexual dysfunction

Answer 31

● First generation: Eg: **Haloperidol** [high potency] and **Chlorpromazine** [low potency] - **EPSEs**: dystonia, parkinsonism, akathisia [unpleasant inner restlessness and strong compulsion to move], tardive dyskinesia - Postural hypotension - **alpha-adrenergic blockade** - Sedation and weight gain - **histamine blockade** - Dry mouth, blurred vision, constipation, urinary retention, glaucoma, ileus - **anticholinergic effect** - Hyperprolactinemia, skin photosensitivity, arrhythmias, sexual dysfunction, NMS ● 2nd generation: Eg: **Clozapine**, Olanzapine, **Risperidone**, Amisulpride, Quetiapine, - **QT prolongation**, arrhythmia, Torsade, impaired glucose tolerance, diabetes, weight gain, dyslipidaemia [metabolic syndrome] and sexual dysfunction ~ - **Clozapine**: For treatment-resistant schizophrenia, intolerable EPSE, negative psychotic features - *Side effects*: **agranulocytosis**, **myocarditis**, **toxic** **megacolon**, seizures, sedation, weight gain, **hypersalivation** - **Neutrophils < 1.5x109 – Stop Clozapine** - Monitoring: WCC – prior to starting treatment then weekly for 18 weeks then every 2 weeks for 6 months then monthly

Answer 32

● First generation: Eg: **Haloperidol** [high potency] and **Chlorpromazine** [low potency] - **EPSEs**: dystonia, parkinsonism, akathisia [unpleasant inner restlessness and strong compulsion to move], tardive dyskinesia - Postural hypotension - **alpha-adrenergic blockade** - Sedation and weight gain - **histamine blockade** - Dry mouth, blurred vision, constipation, urinary retention, glaucoma, ileus - **anticholinergic effect** - Hyperprolactinemia, skin photosensitivity, arrhythmias, sexual dysfunction, NMS

Answer 33

● 2nd generation: o Clozapine, Olanzapine, Risperidone, Amisulpride, Quetiapine, - **QT prolongation** - arrhythmia - Torsade, - impaired glucose tolerance, - diabetes, - weight gain, - dyslipidaemia [metabolic syndrome] and sexual dysfunction

Answer 34

For treatment-resistant schizophrenia, intolerable EPSE, negative psychotic features

Answer 35

▪ Side effects: - agranulocytosis, - myocarditis, - toxic megacolon, - seizures, - sedation, - weight gain, - hypersalivation

Answer 36

▪ Monitoring: WCC – prior to starting treatment - then weekly for 18 weeks - then every 2 weeks for 6 months - then monthly

Answer 37

▪ Neutrophils < 1.5x10^9 – Stop Clozapine

Answer 38

Aetiology: **parent** with **alcohol** dependence, **antisocial**, **ADHD**, conduct disorder and **schizophrenia** OR **sibling** with **disruptive** behaviour **disorder** ● **See** family and the child, **support** the parent, **screen** for high risk families ● Obtain a full **history** with **collateral** from **school**, social worker and **legal** system ● Assess for **comorbidities** and make a diagnosis ● **Formulate** the **problems** and establish **management** plan ● **Address** **child** **protection** concerns ● Treat **comorbidity** ● **Medical** treatment: **antipsychotics** to manage acute and chronic aggression, stimulants such as **Methylphenidate** [Concerta or **Ritalin**] ● **Psychological**: o **Parent** **management** **training**: **education** programmes – provide with **info** of **normal** vs concerning **behaviours**, emphasise a **parenting** **style** that recognises strengths of child/**positive** **reinforcement**/non-punitive punishment, importance of their behaviour model [psychoeducational] o **Child** interventions: **CBT**, social skills, problem-solving, **anger** **management**, **confidence** building o **Functional** **family** therapy o **Multi**-**systemic** therapy: family-based, including school and community ● **Social**: community/**school** interventions, **NGOs** ● **Differential**: **ADHD**, **adjustment** disorder, **autism** spectrum disorder, normal child but parents/teachers have unrealistic expectations, oppositional defiant disorder, **learning** **disability**, **PTSD**, **anxiety** disorder, depression, learning difficulty, **psychosis**, deviance

Answer 39

- **parent** with **alcohol** dependence, - **antisocial**, - **ADHD**, - conduct disorder and **schizophrenia** - **sibling** with **disruptive** behaviour disorder

Answer 40

**antipsychotics** to manage acute and chronic aggression, **stimulants** such as Methylphenidate [Concerta or **Ritalin**]

Answer 41

o **Parent** management training: - education programmes – provide with info of normal vs concerning behaviours, - emphasise a parenting style that recognises strengths of child/positive reinforcement/non-punitive punishment, - importance of their behaviour model [psychoeducational] o **Child** interventions: - CBT, - social skills, - problem-solving, - anger management, - confidence building o Functional **family** therapy o **Multi**-**systemic** therapy: family-based, including school and community

Answer 42

community/school interventions, NGOs

Answer 43

Differential: - **ADHD** - **adjustment** disorder - **autism** spectrum disorder, normal child but parents/teachers have unrealistic expectations, - oppositional defiant disorder, learning disability, - **PTSD** - **anxiety** disorder - **depression** - **learning** **difficulty** - **psychosis** - deviance

Answer 44

● Serotonin/noradrenaline reuptake inhibition: **antidepressant** effects ● **Anticholinergic**: dry mouth, blurred vision, constipation, urinary retention, confusion/memory problems, palpitations/tachycardia ● **Adrenergic** antagonism: postural hypotension, sexual dysfunction ● **5-HT2 (serotonin) antagonism**: anxiolytic, reduced sexual function, sedation ● **Anti-histamine**: drowsiness and weight gain

Answer 45

● **Clinical** features: - impaired ability to direct/**sustain** and shift **attention**, - global **impairment** of **cognition** with disorientation and impairment of recent **memory** and **abstract** **thinking**, - **disturbance** in sleep-wake **cycle** with nocturnal worsening, - **psychomotor** **agitation**, - **emotional** **lability**, - **perceptual** **distortions**, - **speech** may be rambling or **incoherent** and **thought** **disordered**, - poorly developed **paranoid** **delusions**, - **rapid** onset with **fluctuations** in severity over minutes and hours ● **Hyperactive** delirium: **- psychomotor agitation, **- increased **arousal**, - **inappropriate** behaviour, - **delusions** and **hallucinations** ● **Hypoactive** delirium: **- psychomotor retardation, **- **lethargy**, - excess **somnolence** ● Management: o Identify and **treat** precipitating **cause**/exacerbating factors: - **DIMTOP**, (drugs, infrctions, metabolic, trauma, oxygen deficient, psychological) - optimise condition of patient with attention to **hydration**, - **nutrition**, - input and output and **pain** **control** ~ o Provide environmental and **supportive** measures: - **education** to those who interact with patient, - make environment **safe**, - create environment which **optimises** **stimulation** [adequate lighting, reduce noise, mobilise when possible and correct sensory impairment], - reality **orientation** techniques [clear communication, same staff members, clocks and calendars] ~ o Avoid **sedation** unless severely agitated or needed to minimise unnecessary risk - use single medication and start at low dose - Oral **haloperidol** 0.5-1mg daily, - oral **lorazepam** 0.5-1mg daily - oral **risperidone** 1-4mg daily. - Consider antipsychotics first as benzos tend to worsen delirium. - If caused by **alcohol** withdrawal, give **benzos** and thiamine ~ o Regular clinical review and **follow** **up**: - **MMSEs** useful for monitoring cognitive improvement at follow up

Answer 46

Withdrawal Presentation: - **Autonomic** hyperreactivity (high BP and Temp) - Hand **tremor** - **Insomnia** - N&V - Transient **hallucinations** - **Anxiety** - **Psychomotor** **agitation** - GTCS **Management** of acute withdrawal: - **Minor** symptoms above can be treated **supportively** - Can use **benzos**, **phenobarbital** or **Propofol** in status epilepticus Timelines: - **Hallucinations**: at 12-48 hours, usually **visual** - Withdrawal seizures are usual GTCS occur 12-48 hours after last drink - **Delirium** tremens: hallucination, disorientation, tachycardia, hyperthermia, agitation - Sweating typically starts 48-96 hours after last drink **Supportive** care: i. **Benzos** for agitation (IV **diazepam** best) ii. IV **fluid** iii. **Nutritional** support iv. Monitor **vitals** v. **Quite** protective environment vi. **Thiamine** and glucose (**prevent** **Wernicke**’s) vii. **Multivitamins** including **folate** ● **Management**: o **Detoxification** - which involves psychological support, - medication to relieve symptoms, - nutritional supplementation, - observation. - Can be in-patient or in community with support o **Detox**: - decide setting, - assess need for benzos, - consider need for other meds, - verbal and written advice, - inform GP of plans, - give patient a contact in case of emergency, - explicit follow-up o **Outpatient**: - for uncomplicated - if doubts about compliance see daily and breathalyse o **In-patient:** - history of complicated withdrawals, - symptoms of delirium, - comorbid physical/mental illness, - Wernicke’s, - severe n+v, - lack of stable home o **Benzo** **regimen** ▪ Helps with unpleasant withdrawal symptoms and reduces risk of withdrawal seizures ▪ **Diazepam** for in-patient use: faster acting, allows dose titration, can be given parenterally ▪ **Indications**: clinical symptoms of withdrawal, consumption > 10units/day over previous 10 days ▪ Not needed if: <10 units, no history of withdrawal, BAC =0 and no symptoms **o Thiamine – prevent Wernicke’s**

Answer 47

**Symptoms**: o **Autonomic arousal**: tremor, tachycardia, tachypnoea, hypertension, sweating, GI upset. o **Concerns of death** from cardiac or resp problems leading to patients repeatedly presenting. Fear of death/losing control. o **Unexplained medical symptoms:** chest pain, back pain, GI symptoms, headache, fatigue, multiple symptoms o **Suicidal** [or homicidal] ideation, impulsive acts Symptoms: Abrupt **surge** of **fear** with** at least 4** of these present: - **SOB** - Dizziness - Hot **flushes** or chills - **Feeling** of choking - Palpitations - **Nausea**/ abdo discomfort - **Sweating** - Shaking - **Derealization** - Paresthesias - **Fear of dying**/losing control At least **1 attack** has been **followed** by a minimum period of **persistent** **worry** bout further attacks or significant **maladaptive** **change** related to attack ● **Pharmacological**: o **SSRIs**: initially increasing panic symptoms, start with lowest possible dose and gradually increase, may take up to 12 weeks to have beneficial effect. Citalopram 20-30mg, Sertraline 50-200mg o Alternative antidepressants: **SNRIs** [Venlafaxine], **TCA** o **Benzodiazepines**: not really recommended as there is potential for abuse and dependence. Effective for severe, incapacitating symptoms and can be used for 1-2 weeks in combination with antidepressant until the antidepressant becomes ‘effective’ o If rx successful: **continue for 12-18 months **before **trial of discontinuation** with gradual tapering of dose over 2-4 months. Do not confuse withdrawal effects with re-emergence of symptoms **Pharm** 1ST LINE= SSRI (**FLUOXETINE**?) Can **combine with CBT** ● **Psychological**: o **CBT**: treat phobic **avoidance** by **exposure**, **use of relaxation** and **control of hyperventilation**, teach about bodily responses associated with anxiety o **Psychodynamic** **psychotherapy**: ‘**emotion**-**focused**’ treatment where typical **fears** are **explored** **Psychosocial**: **CBT** has been found to be the **best** psychotherapy choice for **panic disorder**. It assists the patient in countering their anxious beliefs, being exposed to fear cues, changing their anxiety-maintaining behaviour. Does require highly motivated patient. And can be **resource intensive.** Psychoeducation is also of use with CBT.

Answer 48

● When patients intentionally falsify their symptoms and past history and fabricate signs of physical or mental disorder with the aim of obtaining medical attention and treatment ● Diagnostic features: intentional and conscious production of signs and falsification or exaggeration of history ● Types: o Wandering: males who move from hospital to hospital, job to job, producing dramatic and fantastic stories. May be aggressive personality or dissocial PD o Non-wandering: female, stable lifestyle and less dramatic, paramedical professions. Chronic somatisation disorder or borderline PD o By proxy: mothers/carers/paramedical/nursing, simulate or prolong illness in their dependents

Answer 49

- **Defaulting** medication [many reasons for non-adherence], - drug **interactions** [inducers], - **incorrect** **dose**/dose not high enough, - **serum** **concentrations** not high enough, - ongoing **substance** use, - treatment **resistance**, - emotional **stressors**, - **incorrect** diagnosis, - **medical** **disease** of liver/kidneys impairing metabolism

Answer 50

● A presentation of **severe depression **in the **elderly** where the combination of **psychomotor retardation**, apparent **cognitive deficits** and **functional decline** cause diagnostic **confusion with dementia** ● **Features**: - previous history of depression, - depressed mood, - exaggerated symptoms, - poor effort on testing, - responds to antidepressants

Answer 51

**● TCAs indications: **- possibly moderate/severe depressive disorders - moderate/severe anxiety states - nocturnal enuresis in child > 11 - neuropathic pain - migraine prophylaxis ● **SSRIs**: - moderate to severe depression, - anxiety but risk of agitation, - bulimia nervosa, - OCD - label for panic disorder, - GAD and some personality disorders **● SNRIs **o Venlafaxine – moderate and major depressive and anxiety disorders o Side effects: Anorexia, nausea, constipation, diarrhoea, hypertension, palpitations, dizziness, insomnia, drowsiness, nervousness, sweating

Answer 52

● **Indications**: acute **bipolar mania**, **maintenance** therapy for **BPD**, **epilepsy**, migraine prophylaxis ● **Dose-related side effects**: - anorexia, - nausea, - dyspepsia, - vomiting, - diarrhoea, - raised LFTs, - tremor, - sedation, - alopecia, - ataxia ● **Unpredictable**: - mild leukopenia and thrombocytopenia - increased appetite - weight gain ● **Rare**: - irreversible liver failure, - pancreatitis, - agranulocytosis, - PCOS/hyperandrogenism ● **Teratogenic**: NTD [ensure contraception and folate]

Answer 53

● Treatment for **depression** particularly if there is **psychotic** symptoms - **failure** of **drug** therapies - patient **preference** - high risk of **suicide** - high risk of medical morbidity and mortality - **catatonia** associated **with SCZ**/MDD/BPMD - treatment **resistant** **mania** - required therapies **contraindicated** in **pregnancy** - **post-natal** depression/psychosis - life-threatening nutritional compromise - **NMS** - neuroleptic malignant syndrome

Answer 54

● **Good**: - **female**, - **rapid** onset of symptoms - **older** age of first episode - predominantly **positive** symptoms - presence of **mood** symptoms - good **pre-illness functioning** ● **Poor**: - **genetic** factors - **substance** use - pregnancy and birth complications such as hypoxia and greater paternal age, - other prenatal/**perinatal issues like stress**, **infection**, **malnutrition** and maternal **diabetes**

Answer 55

● **Antidiuretic** effects leading to hyponatraemia [can develops many months after initiation], - **decrease** in **thyroxine** levels, - **agranulocytosis**, - aplastic **anaemia**, - **hepatic** failure, - exfoliative dermatitis [**SJS**], - **pancreatitis**

Answer 56

● **Behavioural**: **exposure** is the treatment of choice which aims to reduce fear response – **Wolpe**’s systematic desensitisation ● **Cognitive**: **education**/anxiety **management**, **coping** skills, cognitive restructuring ● **Pharmacological**: generally not used unless severe then use **benzos** to **reduce** **fear**/avoidance and allow patient to engage in exposure but this may reduce efficacy of behaviour ● **Other techniques**: reciprocal inhibition, flooding

Answer 57

**Delusional** disorder // *Schizophrenia* Presence of **delusions** for at least **1 month**, **criterion A** for schizophrenia **never met **// *Criterion A: 2+ of, for significant amount of time during 1 month period: delusions, hallucinations, disorganised speech, disorganised behaviour* **Function** **not** **markedly** **impaired** // *Level of social functioning in one or more major areas is below level prior to onset* **Manic**/**depressive** episodes **brief** **compared** to **delusional** periods // *No major depressive or manic episodes have occurred concurrently with active phase symptoms and if they have occurred, they have been present for a minority of the total duration* **Not** **attributable** to physiological effect of substance/other **medical** condition // *Not attributable to physiological effect of substance/other medical condition*

Answer 58

● MHCA form **1** – **emergency** 24-hour admission ● Form **3** – **discharge** form ● Form **4** – application for **involuntary** admission filled in by **family** ● Form **5 x 2** – assessment by **2 physicians** ● Form **6** – **72-hour assessment** ● Form **7** – **admission**, filled in by **med manager** ● Form **8** – approval of **further** **involuntary** care ● Form **11** – **transfer** approval by med manager ● Form **15** – **patient** fills in when they **want to leave** How to do an involuntary admission. ● Fill in a **form 04**: an application in the head of the health establishment for the assessment of a user. Specify that it is as an involuntary patient. - Needs to be** filled out by**: **Someone** who **knows patient** well/sees daily, An associate, MHC practitioner if no one else (would have to specify why it is them filling it in, what efforts were made to find someone, and why you think they need to be admitted) - Everyone must be over 18! ● **Form 04** then needs to be **commissioned** ● Once this is filled in, the patient needs to present within 2 days of the form being filled out. ● **Next**, two separate doctors/MHC practitioners need to do **independent** **assessments** of the patient. At least one must be a doctor. ● They both fill out a **form 05**, which is a continued application to say that they believe the patient needs **further 72** hour assessment. ● If their **assessments** **agree**, a **form 07** is filled in, which is an application to the head of the health establishment to **detail the patient **for 72 hours** for further care** as a designated facility approved for this. When this is **signed by the head of establishment,** is when the 72 hours start. - During the **72 hours**, patient needs to be **seen daily **by a medical doctor and continuous notes must be made. ● **After** that time, **two form 06s** can be filled out (by two independent **MHC practitioners**, as least one is a doctor). ● **After** 72 hour assessment, **all forms submitted **to MHC **review board** who must **fill in a form 13** to say that the hospital has grounds to keep the patient in hospital. ● If the head of **head establishment** believes that the patient needs **further inpatient care after 72 hours,** (s)he fills in a **form 08.** ~ ● If need to be admitted as **emergency** patient: **form 01**. ● If **transferring** patient: **form 11.**

Answer 59

● Mood is depressed but remains reactive, hypersomnia, hyperphagia, leaden paralysis [heaviness in limbs], over-sensitivity to perceived rejection

Answer 60

● Failure to respond to two or more antipsychotic medications given in therapeutic doses for 6 weeks or more ● Mx: o Clarify diagnosis: re-inspect to ensure correct diagnosis o Address comorbidity: substance use is common and worsens outcome o Non-compliance: psychoeducation, compliance therapy, family therapy o Pharmacological: Clozapine depot injection o Clozapine resistance: switching to untried 2nd gen or augmentation with benzamides and anti-epileptics o Rehab: maximise function/QoL and support those who remain symptomatic

Answer 61

● **Bio**: SSRI or SNRI as first line, - requires 4-6 weeks to work, - max effect at 12 weeks, - dose response effect, - may be prescribed on an as needed basis for performance only SAD ● **Psycho**: CBT group or individual, - maintenance sessions, - gradual desensitisation, - stress management and relaxation techniques ● **Social**: family psychoeducation, - assess how it affects job/relationships/family

Answer 62

● Impairment in memory and one or more cognitive deficits, - cognitive decline from previous performance level, - interferes with independence of activities, - not exclusively in delirium setting, - not better explained by another illness ● Slow, - insidious onset with progressive course, - memory impairment, - normal attention and alertness, - usually intact orientation

Answer 63

● **Repeated** **presentation** with medically **unexplained** symptoms affecting **multiple** organ **systems**, first presenting before the age of 40 ● Non-specific and atypical symptoms ● Chronic ● Significant physiological distress and functional impairment and are at risk of iatrogenic harm

Answer 64

● Probable diagnosis: oppositional **defiant** disorder, **conduct** disorder Management: ● **Antipsychotics**: **Risperidone** is the best one to use, treats acute and chronic aggression **● Same management principle as the ADHD question?

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