Psychiatry Flashcards

Question

Major Psychiatric Conditions RFs for vascular dementia?

Answer 1

Male, older age, CVS or cerebrovascular disease, DM, hypertension, cholesterol, smoking, ETOH

Answer 2

Acute fluctuating confusional state with clouding of consciousness, psychotic symptoms and disturbed behaviour

Answer 3

Can be hypoactive (especially poorly detected as not , hyperactive or mixed fluctuates can have paranoid ideas can have hallucinations esp visual can be very frightening for patient and staff

Answer 4

Schizophrenia

Answer 5

Pointers to higher risk; sociopathic personality disorder, alcohol and substance misuse, psychosis, and particularly any combination of these Commanding voices, persecutory delusions, and morbid jealousy. The best predictor of the risk of future violence is a previous history of violence.

Answer 6

Depressed mood Loss of interest or pleasure

Answer 7

Sleep disturbance Appetite & weight changes Reduced energy and concentration Psychomotor changes ``` Negative thinking Loss of confidence / self esteem / worthlessness Self blame / Guilt Suicidal thoughts +/- mood congruent psychotic symptoms ```

Answer 8

28 days. YES YES

Answer 9

6 months YES YES Need AMPH/or relative, 2 docs,

Answer 10

72 hours NO NO Need AMPH/or relative, 2 docs,

Answer 11

6 hours NO NO ONLY NURSE NEEDED

Answer 12

72 Hours NO NO Only one doctor needed.

Answer 13

It is a therapeutic process which helps patients understand and resolve their emotional problems by increasing awareness of their inner world and its influence over relationships both past and present.

Answer 14

``` Key concepts Unconscious Developmental perspective Transference Counter – transference Psychological defence mechanisms ```

Answer 15

Unconscious: mental state that is totally inaccessible to conscious awareness. It is believed that we repress thoughts that are highly exciting and riddled with guilt or shame e.g. aggressive or sexual thoughts, taboo ideas Unconscious ideas exert continual pressure upon the mind, finding expression in dreams, irrational actions and moods

Answer 16

All forms of psychoanalytic therapy emphasise the importance of adequate parenting in the development of the personality: earlier years are focussed upon Hypothesis: A secure early attachment to a “good enough” mother will result in the development of the child’s internalised sense of trust

Answer 17

“a whole series of psychological experiences (that) are revived, not as belonging to the past, but as applying to the person of the physician at the present moment” (Freud, 1905)

Answer 18

``` Denial Projection Splitting Projective identification Regression Conversion Repression Introjection Identification Undoing Displacement Humour Altruism Sublimation ```

Answer 19

Projection 1. Denial of unwanted, usually hated aspects of the personality and experience 2. Splitting off unwanted parts of the Self 3. Attributing these characteristics onto ‘bad’ others.

Answer 20

Displacement | Redirection of thoughts and feelings from on person or object to another that poses less threat.

Answer 21

``` Personality Disorders Complex Depression PTSD Psychosomatic Complaints Eating Disorders ```

Answer 22

Transference: Feelings that the patient has in his/her relationship with the therapist, which gives valuable insight into each individual’s unique way of seeing and relating.

Answer 23

Counter-transference; this is the therapists feelings in his/her relationship towards the patient

Answer 24

A transference interpretation concerns the live experience in the room between the therapist and the patient. It has the advantage of addressing the here and now, something that is emotionally “hot” and immediate in the therapist/patient relationship.

Answer 25

◊ Appearance & Behaviour ◊ Speech ◊ Mood ◊ Thought ◊ Perceptions ◊ Delusions ◊ Cognition ◊ Insight

Answer 26

``` Calculation: Division and Subtraction Right Hemisphere Function: Intersecting pentagons and Clock-face Abstraction: Proverbs and Similarities Memory: STM and Long-term memory Praxis: Wave good-bye and Comb hair ```

Answer 27

``` General: Alertness and Co-operation [STM: Name, Address, Flower to remember] Orientation: Time and Place Attention: WORLD backwards and Serial Sevens Language: Naming and Repetition ```

Answer 28

Risk to self: Suicide, DSH, Neglect Risk to others: Family, carer, general, staff Risk from others: abuse, Safeguarding Risk to property Risk of fire/arson Risk of falls Risk of pressure sore , DVT, dehydration, medication

Answer 29

A →B → C ``` A = Activating Event B = Beliefs - Thoughts, Attitudes, Assumptions C = Consequences - Feelings, Emotions, Behaviors, Actions ```

Answer 30

All or nothing thinking (Dichotomous) Thinking in absolutes, e.g. good or bad, with no middle ground. Judging people or events using general labels, for example: ‘He’s an idiot., ‘I’m hopeless. Catastrophizing Overestimating the chances of disaster; e.g. it’s cancer or if I fail it will be disastrous. Personalising Taking responsibility and blame for anything unpleasant even if it has little or nothing to do with you. e.g. ‘He wouldn’t drink if I was a better wife’ Negative focus Focusing on the negative and ignoring or misinterpreting positive aspects of a situation. Focus on weaknesses and forgetting strengths. e.g. Anyone could have done that, I missed a bit! Jumping to conclusions Making negative interpretations even though there are no definite facts. Predicting the future (fortune telling) and take on the mantle of ‘mind reader’.. e.g. he’s avoiding me, they hate me/It will never work Living by fixed rules Having fixed rules and unrealistic expectations. Regularly using the words ‘should’, ‘ought’, ‘must’ and ‘can’t’.

Answer 31

Having fixed rules and unrealistic expectations. Regularly using the words ‘should’, ‘ought’, ‘must’ and ‘can’t’.

Answer 32

Focusing on the negative and ignoring or misinterpreting positive aspects of a situation. Focus on weaknesses and forgetting strengths. e.g. Anyone could have done that, I missed a bit!

Answer 33

Thinking in absolutes, e.g. good or bad, with no middle ground. Judging people or events using general labels, for example: ‘He’s an idiot., ‘I’m hopeless.

Answer 34

Overestimating the chances of disaster; e.g. it’s cancer or if I fail it will be disastrous.

Answer 35

Personalising Taking responsibility and blame for anything unpleasant even if it has little or nothing to do with you. e.g. ‘He wouldn’t drink if I was a better wife’

Answer 36

Anxiolytics and Hypnotics Hypnotics Antipsychotics Antidepressants Mood stabilizers

Answer 37

Anxiolytics &Hypnotics Act via GABA receptors GABA is principal inhibitory neurotransmitter BDZs enhance the effect of GABA No effect in the absence of GABA or if GABA receptor is blocked Diazepam is a full agonist at the receptor Sedative Anxiolytic Anticonvulsant

Answer 38

Sedative Anxiolytic Anticonvulsant

Answer 39

``` Clinical use Short term use in moderate or severe anxiety Generalised anxiety disorder No longer than 4 weeks Tolerance and dependence Withdrawal symptoms Also used in alcohol detoxification Acute behavioural disturbance. ```

Answer 40

Anxiolytics

Answer 41

Asthma / bronchospasm / COPD Heart failure or heart block Systolic BP below 90mmHg Low pulse rate

Answer 42

Short term use Helps induce sleep Initial insomnia Usually effective after ½ - 1 hour

Answer 43

Benzodiazepines | Z-drugs; Zopiclone; Zimovane; Zalepon.

Answer 44

Zolpidem, Zopiclone, Zalepon Act via GABA – BDZ receptors Shorter elimination ½ life Just as likely to cause rebound insomnia, dependence and neuropsychiatric disturbance Zopiclone may impair driving performance more than BDZ’s.

Answer 45

Flumazenil Competitive antagonist of BDZ’s at the GABA-BDZ receptor Reverses the CNS depressant effects of benzodiazepine overdose Intravenous use only ½ life of 1 hour only

Answer 46

All block DA receptors – D2 Correlation b/w DA receptor binding affinity and clinical potency Clinical response usually achieved with 60% D2 receptor occupancy Greater than 80% occupancy predicts likelihood of extrapyramidal side effects (EPSEs)

Answer 47

``` Reduce hallucinations, delusions and psychomotor excitement Also block noradrenergic and cholinergic receptors ```

Answer 48

Typical or 1st generation Increased risk of acute EPSE’s, hyperprolactinaemia, tardive dyskinesia. haloperidol, chlorpromazine

Answer 49

haloperidol, chlorpromazine

Answer 50

Atypical or 2nd generation Less risk of above Metabolic side effects clozapine, olanzapine, risperidone.

Answer 51

``` Typical depots (FGA’s) – Clopixol, Depixol Atypical depots (SGA’s)– Risperdal Consta, Paliperidone ```

Answer 52

Acute dystonia Akathisia Parkinsonian effects Tardive dyskinesia

Answer 53

``` Rare but potentially fatal All antipsychotics at risk Sympathetic overactivity Fever, sweating, rigidity, confusion, fluctuating consciousness. Labile BP, tachycardia Elevated CPK, Leucocytosis ```

Answer 54

``` High potency typical antipsychotic drugs Recent or rapid dose increase / reduction Abrupt withdrawal of anticholinergics Psychosis Organic brain disease Alcoholism Agitation ```

Answer 55

``` Tricyclic Antidepressants (TCAs) Selective Serotonin Reuptake Inhibitors (SSRIs) Monoamine Oxidase Inhibitors (MAOIs) Others NARIs e.g. Reboxetine SNRIs e.g. Venlafaxine NaSSa e.g. Mirtazepine ```

Answer 56

5-HT & NA re-uptake inhibition Most will also inhibit re-uptake of Dopamine Anticholinergic effects Antihistaminergic effects Amitriptyline; Nortiptyline; Clomipramine; Lofepramine

Answer 57

Amitriptyline; Nortiptyline; Clomipramine; Lofepramine

Answer 58

Sedation Anticholinergic effects Dry mouth, blurred vision, constipation, urinary retention Cardiotoxic – QT prolongation, ST elevation, AV block Discontinuation syndrome Manic switch in bipolar patients

Answer 59

Inhibit re-uptake of 5-HT No significant effect on re-uptake of NA Most widely prescribed antidepressants Relative safety in overdose Relatively less side effects Fluoxetine; Paroxetine; Sertraline

Answer 60

Fluoxetine; Paroxetine; Sertraline

Answer 61

Nausea +/- Vomitting Diarrhoea & Headaches Tolerance usually develops to these within 7-10 days Sexual dysfunction Risk of GI bleed, especially in the elderly Withdrawal syndrome of restlessness/ agitation & increased suicidal ideation

Answer 62

SSRIs can cause ``` Acute toxic syndrome due to increased 5-HT activity Confusion Myoclonic jerks, hyperreflexia Pyrexia, sweating, autonomic instability GI symptoms Mood change, mania Convulsions Death ```

Answer 63

Increase the availability of 5-HT & NA in the synapse Phenelzine, Tranylcypromine, Isocarboxazid ‘Irreversible’ Tyramine Interaction After cessation, recovery occurs slowly, over days Moclobemide - Reversible Inhibitor of MAO-A

Answer 64

Phenelzine, Tranylcypromine, Isocarboxazid ‘Irreversible’ Tyramine Interaction After cessation, recovery occurs slowly, over days Moclobemide - Reversible Inhibitor of MAO-A

Answer 65

Moclobemide - Reversible Inhibitor of MAO-A

Answer 66

Tyramine interaction (Cheese effect) Tyramine is indirect sympathomimetic ``` Can cause hypertensive crises; Flushing Severe throbbing headache Severe hypotension Tachycardia Pallor ```

Answer 67

Found in; mature cheeses; yeast extracts; some red wines; hung game; pickled herrings

Answer 68

``` Experienced with cessation of antidepressant All antidepressants at risk 1/3rd of all patients Receptor rebound Usually within 5 days of stopping Variable intensity Usually mild and self limiting Occasionally severe & life threatening ```

Answer 69

``` Six broad categories; Affective e.g irritability Gastrointestinal e.g nausea Neuromotor e.g ataxia Vasomotor e.g diaphoresis Neurosensory e.g paraesthesia Other neurological e.g increased dreaming ```

Answer 70

Mirtazepine (NaSSA) blocks presynaptic alpha-2 adrenergic receptors. Side effects include drowsiness, increased appetite, and weight gain Venlafaxine (SNRI) similar side effects to SSRI’s Reboxetine(NRIs) noradrenaline reuptake inhibitors

Answer 71

Lithium and anticonvulsant drugs used to treat bipolar affective disorder Treats both poles of bipolar disorder without causing a switch Lithium Sodium valproate Carbamazepine Lamotrigine Atypical antipsychotics

Answer 72

``` Lithium Sodium valproate Carbamazepine Lamotrigine Atypical antipsychotics ```

Answer 73

``` Narrow therapeutic range (0.4-1mmol/L) Regular serum levels required Weekly monitoring at initiation Then every 3-4 months Renal function Pre Lithium. Risk of Hypothyroidism in 10-15% Lithium toxicity ```

Answer 74

``` Electric current: passed briefly through the brain via scalp electrodes applied to the scalp induces generalised seizure activity Patient is given a general anaesthetic Muscle relaxants to prevent body spasms Bilateral or unilateral electrodes ```

Answer 75

Commonest complaint is of muscle pain – 8% 5% complain of confusion or dizziness at some point 30% complain of headache post ECT 20% will complain of memory problems No evidence of structural damage to the brain

Answer 76

``` Severe depression with psychosis and psychomotor retardation Alternative treatments have failed Rapid response is required Dangerous self neglect Resistant psychotic depression ``` Severe depressive illness Catatonia Prolonged or severe manic episode

Answer 77

``` Raised ICP Recent cerebrovascular accident Unstable vascular aneurysms Recent MI with unstable rhythm Treatment of co-existing medical conditions should be optimised before elective treatment ```

Answer 78

Antecedent Behaviour Consequences

Answer 79

``` Impulsive or Planned? Last acts? Attempts to avoid being found? Disinhibiting factors? Prevailing mood? Psychotic symptoms? ```

Answer 80

Method chosen? Actual lethality v perceived lethality Drugs or alcohol have additive effect

Answer 81

``` How were they found? How did they end up in hospital? Regret about attempt v failure of attempt? Compliance with medical intervention? Future plans? Hopelessness What has changed since the attempt? Protective factors ```

Answer 82

Mental Disorder of a nature or degree which warrants detention in hospital (for Ax, & or treatment) Admission necessary in the interests of at least one of these: patient’s health patient’s safety safety of others Patient is unwilling or unable to consent to informal admission ALL 3 of the above have to be present for the MHA to be able to be applied

Answer 83

ALL 4 criteria to be fulfilled: Understand nature and purpose of treatment Retain information for long enough to make an effective decision Be able to weigh up the information provided, as part of the decision making process Communicate the decision Specific to each decision!

Answer 84

Predisposing - why this family Precipitating - why now Perpetuating - what will keep it going Protective

Answer 85

– emotional over-involvement – criticism/hostility – lack of warmth.

Answer 86

Co-ordinator and takes the lead in the process Will have detailed local knowledge Conveys the patient to the hospital Lots of experience of the practicalities Doctors make medical recommendations and the AMHP has the final decision.

Answer 87

Section 135 (1) – Warrant to search and remove AMPH applies to Magistrates Court for warrant to gain access to property to look for and remove an ill patient to a ‘place of safety’ (usually a hospital) Executed by the police who must be accompanied by an AMHP and a doctor. Can result in 72 hour admission for assessment (Rx under MCA)

Answer 88

Section 135 (1) – Warrant to search and remove AMPH applies to Magistrates Court for warrant to gain access to property to look for and remove an ill patient to a ‘place of safety’ (usually a hospital) Executed by the police who must be accompanied by an AMHP and a doctor. Can result in 72 hour admission for assessment (Rx under MCA)

Answer 89

Section 136 – Police power of arrest Power for police to remove a mentally ill person from a public place to a place of safety Can result in 72 hour admission for assessment. (Rx under MCA)

Answer 90

Section 136 – Police power of arrest Power for police to remove a mentally ill person from a public place to a place of safety Can result in 72 hour admission for assessment. (Rx under MCA)

Answer 91

Section 2 (Admission for Assessment) To be used when the diagnosis is unclear or (rarely) for the non-compliant not obviously ill patient. Lasts up to 28 days. Requires two doctors, one Section 12 Approved, and an Approved Mental Health Professional (AMHP)

Answer 92

Section 2 (Admission for Assessment) To be used when the diagnosis is unclear or (rarely) for the non-compliant not obviously ill patient. Lasts up to 28 days. Requires two doctors, one Section 12 Approved, and an Approved Mental Health Professional (AMHP)

Answer 93

``` Section 3 (Admission for Treatment) To be used where the diagnosis is clear, usually a known patient. Lasts up to six months and renewable. Requires two doctors, one Section 12 Approved, and an AMHP ```

Answer 94

``` Section 3 (Admission for Treatment) To be used where the diagnosis is clear, usually a known patient. Lasts up to six months and renewable. Requires two doctors, one Section 12 Approved, and an AMHP ```

Answer 95

Section can be renewed for 6/12 and then 1 year.

Answer 96

Legal right to appeal to the MH review tribunal | Can obtain leave under section 17

Answer 97

Admission for assessment in cases of emergency, where waiting for a second doctor would cause undesirable delay. Requires one doctor and an AMHP Rarely used – eg. If 2 drs cannot be found in time for S2 Lasts up to 72 hours

Answer 98

Admission for assessment in cases of emergency, where waiting for a second doctor would cause undesirable delay. Requires one doctor and an AMHP Rarely used – eg. If 2 drs cannot be found in time for S2 Lasts up to 72 hours

Answer 99

Consultant Psychiatrist or nominated deputy (with full GMC registration IE FY1) Patient suspected to be suffering from a mental disorder Detention for up to 72 hours Allows time for an MHA Assessment Does not authorise treatment for mental disorder.

Answer 100

Must be an inpatient. Cannot be used in A&E or in outpatients. To detain a patient receiving care for a physical condition on a general ward who is suspected of having a mental disorder. * MCA cannot be used to detain a patient * Nurse’s holding power S5(4) lasts up to 6 hours

Answer 101

Can be used once a patient is discharged from a section 3 (and certain forensic sections) Gives the Responsible Clinician power to recall the patient back to hospital Can’t be used to compel a patient with capacity to take treatment Can last initially for 6 months, renewed for 6/12, then 1 year

Answer 102

Framework for decision-making on behalf of people who lack capacity Identifies how best interests are determined Applies to people aged 16 and over Decisions can be wide-ranging, simple or complex and include decisions regarding medical treatment for both physical and mental disorder

Answer 103

Understand the risks, benefits and alternatives related to their decision Retain that information long enough to make the decision Weigh up that information Communicate the decision through any means

Answer 104

1) the person lacks capacity – the MCA applies Or 2) the person is detained under MHA - which can provide an authority to treat mental disorder

Answer 105

18 years and over, with mental disorder, lacking capacity in relation to their care and Rx and would come to harm if not detained IE BEING TREATED NOT FOR THE MENTAL HEALTH CONDITION

Answer 106

Acute stress disorder (ASD) is characterized by acute stress reactions that may occur in the initial month after a person is exposed to a traumatic event (threatened death, serious injury, or sexual violation). The disorder includes symptoms of intrusion, dissociation, negative mood, avoidance, and arousal.

Answer 107

5-20% point prevalence Epidemiology varies by types of trauma: ●Motor vehicle accident – 13 percent, 21 percent ●Mild traumatic brain injury – 14 percent ●Assault – 16 percent, 19 percent ●Burn – 10 percent ●Industrial accident – 6 percent, 12 percent ●Witnessing a mass shooting – 33 percent

Answer 108

Dissociating trauma memories and their associated affect from normal awareness impedes processing of these reactions and thereby leads to subsequent PTSD Fear conditioning - fear elicited during a traumatic event results in conditioning - subsequent reminders of the trauma elicit anxiety in response to trauma reminders. Extreme sympathetic arousal at the time of a traumatic event -> release of stress neurochemicals (including norepinephrine and epinephrine) that results in overconsolidation of trauma memories Most trauma survivors successfully engage in extinction learning in the days and weeks after trauma as they learn that the reminders are not signaling further threat. Evidence that people who eventually develop PTSD display elevated heart rate in the days after the trauma People with elevated respiration rate after trauma are more likely to develop PTSD. These findings underscore the proposal that elevated arousal in the acute phase is important in the etiology of ASD and PTSD.

Answer 109

●History of a pretrauma psychiatric disorder ●History of traumatic exposures prior to recent exposure ●Female gender ●Trauma severity ●Neuroticism ●Avoidant coping

Answer 110

Acute stress disorder (ASD) typically presents with severe levels of re-experiencing and anxiety in response to reminders of the recent trauma. ``` Nightmares Intrusive memories Vivid recollections Perceptual memories Avoidant behaviour Flat / blunted affect Emotional numbing Distress on recall of trauma Amnesia of core aspects of the event ```

Answer 111

A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways: •1. Directly experiencing the traumatic event(s) •2. Witnessing, in person, the event(s) as it occurred to others •3. Learning that the event(s) occurred to a close family member or close friend Note: In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. •4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (eg, first responders collecting human remains, police officers repeatedly exposed to details of child abuse) Note: This does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related. ●B. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred: •Intrusion symptoms -1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed. -2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s). Note: In children, there may be frightening dreams without recognizable content. -3. Dissociative reactions (eg, flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play. -4. Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). •Negative mood -5. Persistent inability to experience positive emotions (eg, inability to experience happiness, satisfaction, or loving feelings). •Dissociative symptoms -6. An altered sense of the reality of one's surroundings or oneself (eg, seeing oneself from another's perspective, being in a daze, time slowing). -7. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). •Avoidance symptoms -8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). -9. Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). •Arousal symptoms -10. Sleep disturbance (eg, difficulty falling or staying asleep, restless sleep) -11. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects -12. Hypervigilance -13. Problems with concentration -14. Exaggerated startle response ●C. Duration of the disturbance (symptoms in Criterion B) is three days to one month after trauma exposure. Note: Symptoms typically begin immediately after the trauma, but persistence for at least three days and up to a month is needed to meet disorder criteria. ●D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. ●E. The disturbance is not attributable to the physiological effects of a substance (eg, medication or alcohol) or another medical condition (eg, mild traumatic brain injury) and is not better explained by brief psychotic disorder.

Answer 112

Trauma survivors often display symptoms of marked distress in the initial days and weeks after a traumatic event, but then the majority of people tend to adapt, and these symptoms remit. CBT first line Mindfullness Pharmacological - antidepressants may help

Answer 113

Although there is considerable variability across studies, between 40 and 80 percent of those with ASD develop subsequent PTSD; that is, half or more of people with ASD do not experience chronic PTSD.

Answer 114

Trauma survivors often display symptoms of marked distress in the initial days and weeks after a traumatic event, but then the majority of people tend to adapt, and these symptoms remit.

Answer 115

An adjustment disorder (AD)—sometimes called exogenous, reactive, or situational depression—occurs when an individual is unable to adjust to or cope with a particular stress or a major life event. Since people with this disorder normally have symptoms that depressed people do, such as general loss of interest, feelings of hopelessness, and crying, this disorder is sometimes known as situational depression. Unlike major depression, the disorder is caused by an outside stressor and generally resolves once the individual is able to adapt to the situation. According to the DSM-IV-TR, if the AD lasts less than six months, then it may be considered acute. If it lasts more than six months, it may be considered chronic.

Answer 116

5–21% among psychiatric consultation services for adults M:F 1:2 M=F in adolescents

Answer 117

A stressor is generally an event of a serious, unusual nature that an individual or group of individuals experience. The stressors that cause adjustment disorders may be grossly traumatic or relatively minor, like loss of a girlfriend/boyfriend, a poor report card, or moving to a new neighborhood. It is thought that the more chronic or recurrent the stressor, the more likely it is to produce a disorder. The objective nature of the stressor is of secondary importance. Stressors' most crucial link to their pathogenic potential is their perception by the patient as stressful. The presence of a causal stressor is essential before a diagnosis of adjustment disorder can be made. There are certain stressors that are more common in different age groups: Adulthood: Marital conflict Financial conflict Health issues with oneself, partner or dependent children Personal tragedy such as death or personal loss Loss of job or unstable employment conditions e.g. corporate takeover or redundancy Adolescence and childhood: Family conflict or parental separation School problems or changing schools Sexuality issues Death, illness or trauma in the family

Answer 118

Younger age; More identified psychosocial and environmental problems; Increased suicidal behaviour, more likely to be rated as improved by the time of discharge from mental healthcare; Less frequent previous psychiatric history; Shorter length of treatment.

Answer 119

According to the DSM IV-TR, the development of the emotional or behavioral symptoms of this diagnosis have to occur within three months of the onset of the identifiable stressor(s).[6] Some emotional signs of adjustment disorder are: ``` Sadness Hopelessness Lack of enjoyment Crying spells Nervousness Anxiety Worry Desperation Trouble sleeping Difficulty concentrating Feeling overwhelmed and thoughts of suicide Reckless driving Ignoring important tasks such as bills or homework Avoiding family or friends Performing poorly in school/work Skipping school/work ```

Answer 120

The DSM-5 defines adjustment disorder as “the presence of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s)” One or both of these criteria exist: Distress that is out of proportion with expected reactions to the stressor Symptoms must be clinically significant—they cause marked distress and impairment in functioning Further, these criteria must be present: Distress and impairment are related to the stressor and are not an escalation of existing mental health disorders The reaction isn’t part of normal bereavement Once the stressor is removed or the person has begun to adjust and cope, the symptoms must subside within six months. 6 SUBTYPES: The DSM-5 criteria for each type of adjustment disorder relate to its specific symptoms. The manual specifies adjustment disorder with Depressed mood Anxiety Mixed depressed mood and anxiety Disturbance of conduct Mixed disturbance of emotions and conduct Unspecified (symptoms don’t quite meet the criteria for any of the defined categories)

Answer 121

Psychotherapy - for symptom relief and behaviour change Counselling Crisis intervention Family therapy Behaviour therapy Self-help group treatment = are often used to encourage the verbalization of fears, anxiety, rage, helplessness, and hopelessness. Small doses of antidepressants / anxiolytics Because natural recovery is the norm, it has been argued that there is no need to intervene unless levels of risk or distress are high. FOR CHILDREN: offering encouragement to talk about their emotions; offering support and understanding; reassuring the child that their reactions are normal; involving the child's teachers to check on their progress in school; letting the child make simple decisions at home, such as what to eat for dinner or what show to watch on TV; having the child engage in a hobby or activity they enjoy.

Answer 122

Because natural recovery is the norm, it has been argued that there is no need to intervene unless levels of risk or distress are high.

Answer 123

Prolonged grief disorder (PGD) refers to a syndrome consisting of a distinct set of symptoms following the death of a loved one. The affected person is incapacitated by grief, so focused on the loss that it is difficult to care about much else. He or she often ruminates about the death and longs for a reunion with the departed, while feeling unsure of his or her own identity and place in the world. The victim will develop a flat and dull outlook on life, feeling that the future holds no prospect of joy, satisfaction or pleasure. The bereaved person who suffers from PGD feels devalued and in constant turmoil, with an inability to adjust to (if not a frank protest against) life without the beloved.

Answer 124

PGD is relatively rare – experienced by about 10 percent

Answer 125

Loss of a loved / close person

Answer 126

``` Miscarriage Childhood separation anxiety Controlling parents Parental abuse or death Close kinship relationship to the deceased (e.g., parents) Insecure attachment styles Emotional dependency Lack of preparation for death Death in hospital No shortened rapid eye movement (REM) latency Activation of the nucleus accumbens ```

Answer 127

``` Intense yearning Identity confusion Difficulty accepting the loss Bitterness Emotional numbness Loss of trust Feeling of trapped in grief ``` These are present every day, causing significant distress and functional impairment, and remaining intense, frequent, and disabling for six months or more after the death. Normal grief differs from PGD in that it is not as intense, persistent, disabling and life-altering and is not experienced as a severe threat to the survivor's identity, sense of self-worth, feeling of security, safety or hopes for future happiness.

Answer 128

Category A) Event - bereavement B) Yearning to disabling degree C) Cognitive, emotional and behavioural symptoms: (need 5) Confusion about role in life Difficulty accepting loss Avoidance of reminders of reality of the loss Loss of trust Bitterness/anger Difficulty moving on Numbness Feeling that life is unfulfilling/empty/meaningless Stunned/shocked D) Timing: diagnosis should not be made until 6 months have elapsed E) Impairment on daily functioning F) Disturbance is not accounted for by another mental illness

Answer 129

TCAs | Interpersonal psychotherapy

Answer 130

Elevated rates of suicidal ideation and attempts Cancer Immunological dysfunction Hypertension Cardiac events Functional impairment Adverse health behaviors Reduced quality of life in adults and in children Increased health service use and sick leave

Answer 131

Generalised anxiety disorder (GAD) is defined as at least 6 months of excessive worry about everyday issues that is disproportionate to any inherent risk, causing distress, or impairment. The worry is not confined to features of another mental disorder, or as a result of substance abuse or a general medical condition. At least 3 of the following emotional, somatic, and cognitive symptoms are present most of the time: restlessness or nervousness, being easily fatigued, poor concentration, irritability, muscle tension, or sleep disturbance. Other common complaints are autonomic in nature, such as sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort. Anxiety may be 'free-floating' (i.e., not restricted to, or even strongly predominating in, any particular environmental circumstances).

Answer 132

76% of people who had more than 1 mental disorder for 12 months had GAD. Estimates for 1-month prevalence in Europe are 0.2% to 1% with a lifetime prevalence of 0.1% to 21.7%. In women, there is an increased risk of GAD during pregnancy (with a 4.1% prevalence during pregnancy overall according to one large study) and also in the postnatal period (5.7% prevalence in the first 24 weeks after birth).

Answer 133

No single aetiology exists, but an increase in minor life stressors, presence of physical or emotional trauma, and genetic factors seem to contribute.

Answer 134

``` STRONG Fix Physical/emotional stress Hx physical or emotional trauma Other anxiety disorder Female ``` WEAK DM Adolescence / early adulthood

Answer 135

``` COMMON RFs Excessive worry for at least 6 months Anxiety not confined to another disorder Anxiety not due to medication/substance Not due to organic cause Muscle tension Sleep disturbance Fatigue Restlessness Irritability Poor concentration ``` ``` OTHER COMMON Headache Sweating Dizziness GI symptoms Muscle aches Increased heart rate SOB Trembling Exaggerated startle response Chest pain ```

Answer 136

DSM-V Excessive anxiety and worry regarding several issues are present most of the time for more than 6 months. Difficulty controlling worry. At least 3 symptoms associated with anxiety for the past 6 months: Restlessness or feeling on edge Easily fatigued Difficulty concentrating Irritability Muscle tension Sleep disturbance (difficulty falling or staying asleep, or restless sleep). Anxiety causes significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not better explained by another mental disorder (e.g., worries about having a panic attack in panic disorder), worries about embarrassment in public (social phobia), fear of contamination (OCD), separation anxiety; fear of gaining weight (anorexia nervosa), multiple physical complaints (somatisation disorder), fear of a serious illness (hypochondriasis), or exclusively due to PTSD. The disturbance is not attributable to the physiological effects of a substance or another medical condition. ``` CONSIDER: TFTs Urine drug screen 24hr urine collection Pulmonary FTs ECG Echocardiogram EEG ```

Answer 137

``` 1) Pharmacology: Sertraline Duloxetine ...basically any SSRI/SNRI/TCA 2) BDZ - clonazepam CBT Applied relaxation Meditation training Sleep hygiene education Exercise Self-help Augmented treatment ``` PREGNANT CBT 1st line Then all the other non-pharmacological interventions

Answer 138

Depression Substance abuse Over-use of healthcare resources Pharmacotherapy should be given for at least 6 to 8 weeks to determine efficacy, and in the author’s clinical experience should be continued for at least 12 months if effective. Depression co-occurs in 30% to 60% of patients and increases the risk for suicidality. Patients with depression and GAD have a more severe and prolonged course.

Answer 139

generalised anxiety disorder

Answer 140

generalised anxiety disorder

Answer 141

Obsessive-compulsive disorder (OCD) is a frequently debilitating and often severe anxiety disorder that affects approximately 2% of the population. OCD is characterised by: (a) obsessions, defined as unwanted, disturbing, and intrusive thoughts, images, or impulses that are generally seen by the patient as excessive, irrational, and ego-alien; and (b) compulsions, defined as repetitive behaviours and mental acts that neutralise obsessions and reduce emotional distress. OCD causes significant distress and impairment in daily functioning and can have a substantial effect on the sufferer's quality of life. Obsessions and/or compulsions that cause marked distress, are time consuming (take more than 1 hour per day), or interfere substantially with the person's normal routine, occupational or academic functioning, or usual social activities or relationships. If the content of the obsessions or compulsions is limited to the scope of another psychiatric disorder, such as an obsession with food in the context of an eating disorder, then an additional diagnosis of OCD should not be made. The Yale-Brown Obsessive-Compulsive Scale is useful in grading severity initially and following trials of therapy. Patients tend to seek treatment from 3 to 4 doctors and spend on average around 9 years in treatment before a correct diagnosis is made. The average amount of time that lapses between onset of symptoms and appropriate treatment is 17 years. Cognitive behavioural therapy in the form of exposure and response prevention, alone or in combination with a selective serotonin-reuptake inhibitor (SSRI) or clomipramine, is a first-line therapy. While controlled trials with SSRIs have demonstrated a selective efficacy in OCD, up to 40% to 60% of patients do not have a satisfactory outcome.

Answer 142

OCD affects 2% to 3% of the population and it is estimated that OCD is the fourth most common mental illness. M=F 22-36yo onset

Answer 143

OCD most probably results from a confluence of aetiologies. Genetic factors are important, as monozygotic twins are much more likely to exhibit OCD symptoms than dizygotic twins. In addition, there is an association between pregnancy and the development of obsessive-compulsive symptoms. In one study of 59 female OCD patients, 39% of participants described an onset of OCD symptoms during pregnancy.

Answer 144

STRONG FHx PANDAS - PANDAS (paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection) - OCD symptoms can be caused or exacerbated by an autoimmune reaction in which antibodies to beta-haemolytic streptococci cross-react with proteins in the basal ganglia WEAK Pregnancy Male - earlier onset/more chronic/Rx resistance ``` Rx Resistance RFs: Earlier onset Hospitalisations for OCD Higher freq. complulsions Schizotypical personality disorder Tic disorder Poor motor control Sensory perceptual difficulties ```

Answer 145

COMMON Obsessions: Intrusive, unwanted, anxiogenic thoughts that result in marked distress. Patient typically recognises that these thoughts are irrational. Common obsessions include fear of contamination, need for symmetry or exactness, fear of causing harm to someone, sexual obsessions, religious obsessions, fear of behaving unacceptably, and fear of making a mistake. Compulsions: Repetitive behavioural or mental acts that are designed to neutralise the anxiety that results from obsessions. Compulsions result in a temporary relief of anxiety and are self-reinforcing. Common behavioural compulsions include cleaning, hand washing, checking, ordering and arranging, hoarding, and seeking reassurance from others. Common mental compulsions include counting, repeating words silently, ruminating, and attempting to 'neutralise' thoughts.

Answer 146

Structured clinical interview for the DSM (SCID) - The SCID is a structured instrument that can be used to determine whether or not a patient meets DSM criteria for OCD. Yale-Brown Obsessive-Compulsive Scale - Not a diagnostic tool, but a reliable measure of symptom severity. Should be administered at the start of treatment and periodically (every 6 months) in order to track treatment progress. [

Answer 147

Mild-Mod CBT 1st line - involves exposure and response prevention Pharm: Fluoxetine / Sertraline / clomipramine At 12 weeks, if a patient has exhibited a partial response to an agent, one might prefer to utilise augmentation strategies instead of switching to a different drug. Augmentation strategies include: increasing the current medication to the highest tolerable dose; using intravenous citalopram or clomipramine (however, these formulations are not available in general clinical settings in the US); or combining regimens (e.g., selective serotonin-reuptake inhibitor [SSRI] plus clomipramine, [90] or SSRI plus an antipsychotic medication). Caution is advised when using citalopram, due to association with QT interval prolongation. Special caution is advised in those over 60 years of age or in those who have pre-existing potential for QTc prolongation/arrhythmias either due to inherent disease or due to other concomitant medications. If the patient does not respond to the highest tolerated dose of SSRI for 12 weeks, augmentation with an antipsychotic medication may be considered.

Answer 148

anxiety disorder: obsessive compulsive disorder

Answer 149

anxiety disorder: obsessive compulsive disorder

Answer 150

Panic disorder is characterised by recurring unexpected panic attacks over a 1-month period and associated worry about their recurrence or implications. Panic attacks involve the sudden onset of intense physical and cognitive symptoms of anxiety that may be triggered by specific cues or occur unexpectedly. Panic disorder may also be characterised by avoidance of situations that may trigger the panic sensations.

Answer 151

8-28% have a panic attack Panic disorder prevalence - 2% to 3% for adolescents and adults Develop in 20s Men present earlier than women Panic disorder is highly comorbid with other anxiety, mood, and substance use disorders, including nicotine dependence. Comorbidity with depressive disorders is common (33% to 85%) especially among those with agoraphobia.

Answer 152

Genetic factors: the risk of panic disorder increases fivefold among first-degree relatives. Environmental factors: panic attacks, by definition, initially occur unexpectedly. However, they do happen in context, and thus certain features of the environment may become triggers that elicit intense anxiety symptoms. Significant histories of unpredictable and uncontrollable life stressors and trauma are common. Psychological factors: cognitive behavioural models of panic assume that repeated, unpleasant experiences with external (e.g., crowds) and internal (e.g., rapid heartbeat) triggers lead to selective attention and hypervigilance.

Answer 153

``` STRONG Hx in 1st deg relative 18-39 Female White Major life event Comorbid disorders Psychological factors Asthma/respiratory association CS + caffeine use ``` WEAK Cardiac abnormalities

Answer 154

``` COMMON RFs Unexpected onset - Up to 70% of patients report at least 1 nocturnal panic attack. Apprehension/worry Behavioural avoidance Tachycardia PRIME-MD panic screen (4 points) Panic disorder severity scale - A 7-item measure assessing the frequency, avoidance, degree of distress, and functional impairment of panic attacks ``` ``` Palpitations, chest pain, discomfort Nausea Abdo pain Dizziness Perceptual abnormality [derealisation/depersonalisation] Hyperventilation, shortness of breath, smothering sensations, and a feeling of choking. Paraesthesias Muscle shaking Sweating Fainting Chills/hot flushes ```

Answer 155

Clinical ``` Potential: ECG BG - hypoglycaemia rule out TFTs - hyper Toxicology screen ```

Answer 156

ACUTE Benzo+reassurance ONGOING 1. CBT - CBT for panic disorder involves a combination of education, self-monitoring, relaxation training, challenging negative styles of thinking, situational exposure training, and systematic exposure to uncomfortable physical sensations. 2. SSRI/SNRI Sertraline/fluoxetine/citalopram 3. BDZ - lorazepam/clonazepam - although physiological dependence can occur in as little as 2 to 4 weeks. Dual therapy

Answer 157

Serotonin withdrawal syndrome Substance abuise Ambivalence towards mental health referral or excessive fears of cognitive behavioural psychotherapy

Answer 158

panic disorder

Answer 159

panic disorder

Answer 160

The condition involves an excessive fear of social or performance situations. The individual will often fear being embarrassed, or worry about being negatively evaluated by others. Anticipatory anxiety and situational avoidance are common, and the individual may endure social situations with a high level of discomfort. The scope of the anxiety may be focused on specific types of social situations or generalised to almost any social encounter. Characterised by an excessive fear of social and performance situations where the individual is afraid of being embarrassed or negatively evaluated by others. One of the most common and impairing mental disorders with a high risk for comorbid anxiety, depressive, and substance-use/abuse-related disorders. Assessment is based on self-reporting, clinical interview, and behavioural observation. Selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and cognitive behavioural therapy are considered the first-line treatments. Long-term clinical management and monitoring are typically required, as patients are prone to relapse following discontinuation of acute treatment.

Answer 161

A combination of biological, familial, experiential, and cultural factors contributes to the risk of developing social anxiety. Temperament factors, such as behavioural inhibition, shyness, introversion, and anxiety sensitivity, have also been implicated as risk factors for social anxiety. Familial factors, such as parental over-control, over-protection, and lack of warmth, may also contribute to insecure attachment styles and social anxiety risk. Adverse life experiences, including transitions, humiliation, losses, and poverty, may also play a role in the development of social anxiety. Conditioning models of anxiety propose that multiple social cues can develop the capacity to elicit anxiety-related symptoms. Learned escape and avoidance behaviours maintain the anxiety, interfere with skill development, and can lead to increasing levels of functional impairment and disability over time. Similarly, safety behaviours, such as only entering into social situations with a trusted companion, averting eye contact, and staying on the periphery of social gatherings, may also maintain anxiety-related impairments.

Answer 162

Late childhood - adolescence 5-12% lifetime estimates The prevalence of social anxiety in pre-adolescence is 3.5%, with rates increasing to about 14% during adolescence Gender distribution tends to be generally equal during pre-adolescence, becoming increasingly more common in females than in males through adolescence and adulthood.

Answer 163

``` STRONG Psychiatric comorbidity Genetic Temperamental factors Parenting style Psychological disorder Life stressors Environmental factors ```

Answer 164

``` COMMON RFs Anticipatory anxiety Tachycardia Hyperventilation Sweating Flushing Muscle tension Post-event processing Attentional biases Social skills deficits Crying, tantrums or freezing ```

Answer 165

Clinical - DSMV Diagnostic and statistical manual of mental disorders, fifth edition (DSM-5) Marked fear or anxiety in one or more social or performance situations in which the person is exposed to possible scrutiny by others. Fear that they will act in a way (or show anxiety symptoms) that will be humiliating, embarrassing, or they will be rejected by others. Exposure to the feared social situation almost invariably provokes anxiety or a panic attack. The fear or anxiety is out of proportion to the actual threat of the situation. Feared social or performance situations are either avoided or endured with intense anxiety or distress. The fear or avoidance interferes significantly with the person's normal routine, occupational functioning, relationships, or social activities. For children and adults, the duration of symptoms must be at least 6 months. The fear or avoidance is not due to the direct physiological effects of a substance or a general medical condition, and is not better accounted for by another mental disorder. If a general medical condition or another mental disorder is present, the social anxiety disorder is unrelated to it. The diagnosis can be further specified as 'performance only' if the anxiety is focused specifically on public speaking or performing in public to a degree that there is marked functional impairment (e.g., interfering with ability to work). In children: The anxiety must occur in peer settings, and not just in interactions with adults The anxiety may also be expressed by crying, tantrums, 'freezing', or shrinking from social situations with unfamiliar people. Consider Blood glucose (hypo) TSH - normal/abnormal Urine/blood toxicology

Answer 166

1) 12 week CBT 1) Sertraline Citalopram Fluoxetine Duloxetine For those patients who prefer pharmacological therapy, SSRIs or SNRIs are first-line therapies. The treatment period needs to be at least 12 weeks. Following response, treatment for up to 12 months or longer is recommended to prevent relapse. 2) Clonazepam/alprazolam - caution abuse 3) MAOI - phenelzine or moclobemide 3) Gabapentin/pregabalin

Answer 167

This is among the most common and disabling mental disorders. It can be chronic, and access to treatment is often delayed or avoided. About 70% to 80% of cases have a lifetime history of concurrent anxiety, depression, and/or substance abuse-related disorders. Relapse may occur in 30% to 50% of patients following medication discontinuation. Complications: Serotonin withdrawal syndrome Substance abuse Risk of suicide with SSRI Rx

Answer 168

Social anxiety disorder

Answer 169

Phobias involve intense fears of specific objects or situations that are triggered upon actual or anticipated exposure to phobic stimuli. Situations in which phobic cues are present are usually avoided or endured with intense anxiety. Excessive fears can cause functional impairments or lifestyle disruptions. One of the most common and treatable psychiatric conditions. Marked by fear or anxiety in the presence of a specific object or situation. Assessments are based on self-reports, clinical interviews, and behavioural observations. Cognitive behavioural therapy, especially exposure therapy, is considered the first-line treatment for patients with frequent symptoms. Therapy can also be delivered through self-help, computer-assisted, and/or therapist-assisted modalities. Patient motivation and available resources are important to consider when reviewing treatment options.

Answer 170

Lifetime prevalence is between 9% and 13% 12-month prevalence is between 7% and 9% 18 per 1000 F:M 3:1 Approximately 70% of specific phobics report more than one clinically relevant fear. Animals and heights tend to be the most common stimuli, followed by flying, enclosed spaces, and blood-injection-injury.

Answer 171

Intense anxiety or unexpected panic responses in the presence of specific objects or situations can mark phobia onset, but this is not necessarily the only causal route to phobic acquisition. Disgust, either alone or in combination with fear, may be involved in the onset and maintenance of various animal (e.g., spiders, snakes, worms) and blood-injection-injury phobias. Onset can also occur through indirect means, such as observing others reacting fearfully or receiving negative information. However, a past event or specific reason for the onset of a phobia is not always possible to identify. Some phobias (e.g., animal phobias) may arise solely due to the evolutionary threat relevance of their stimuli. Familial concordance rates among first-degree biological relatives tend to be moderate. Heritability studies suggest that animal and blood-injection-injury phobias have the greatest heritability indices, of roughly 32% and 33%, respectively; however, there is limited research in this area.

Answer 172

``` STRONG somatisation disorder anxiety disorders mood disorders first-degree relative with phobia twin with phobia ``` ``` WEAK aversive experiences stress and negative life events female sex white ethnicity parental anxiety and overprotectiveness negative affectivity and behavioural inhibition cognitive/attentional bias ```

Answer 173

``` COMMON Anticipatory anxiety Behavioural avoidance Onset during childhood/early adulthood Nausea Dizziness Disgust Fainting Tachycardia Hyperventilation Exaggerated startle Sleep disruption ```

Answer 174

Self report Behaviour observation/approach test DSMV: Marked and persistent fears that are cued by the presence or anticipation of specific objects or situations. Exposure to phobic stimuli almost invariably provokes immediate anxiety responses, including increased physiological arousal. In children, anxieties may be expressed by crying, tantrums, freezing, or clinging. Phobic situations are avoided or endured with intense anxiety or distress. The fear or anxiety is out of proportion to the actual danger posed by the threatening object or situation. Avoidance, anxious anticipation and/or distress of feared situations interferes significantly with normal routines, occupations or academic functions, social activities, and/or relationships. Symptoms have been present for at least 6 months in both children and adults. Symptoms are not better accounted for by other mental disorders. Subtypes are specified based on the following phobia categories. Animal: dogs, snakes, insects, etc. Situational: driving, flying, enclosed spaces, etc. Natural environment: storms, heights, dark, etc. Blood-injection-injury: injections, blood draws, medical procedures, etc. Other: choking, vomiting, clowns, etc.

Answer 175

Education: Advise patients that fear is an inevitable and normal part of life, but that avoidance behaviours can feed a particular fear to the point it interferes with everyday life and becomes a phobic disorder. Encourage patients to face their fears, rather than avoid them. CBT and exposure therapy If fainting - applied tension ``` BDZ Alprazolam Clonazepam Lorazepam Diazepam ```

Answer 176

``` Complications Anxiety disorder Depression Non-compliance with medical regimens Apprehension/stigma of MH referrals Resistance to exposure therapy ``` Up to 90% of patients reach clinically significant levels of improvement after treatment with exposure therapy.

Answer 177

``` Complications Anxiety disorder Depression Non-compliance with medical regimens Apprehension/stigma of MH referrals Resistance to exposure therapy ``` Up to 90% of patients reach clinically significant levels of improvement after treatment with exposure therapy.

Answer 178

Agoraphobia is a fear of being in situations where escape might be difficult or that help wouldn't be available if things go wrong. Many people assume agoraphobia is simply a fear of open spaces, but it's actually a more complex condition. Someone with agoraphobia may be scared of: travelling on public transport visiting a shopping centre leaving home ``` May be related to: Attachment theory Spatial theory (discussed) Evolutionary theory Substance abuse (chronic BDZ use) ```

Answer 179

M:F 1:2 Agoraphobia affects about 1.7% of adults 1/3 of this population with panic disorder have comorbid agoraphobia

Answer 180

Individuals without agoraphobia are able to maintain balance by combining information from their vestibular system, their visual system, and their proprioceptive sense. A disproportionate number of agoraphobics have weak vestibular function and consequently rely more on visual or tactile signals. They may become disoriented when visual cues are sparse (as in wide-open spaces) or overwhelming (as in crowds).

Answer 181

``` rapid heartbeat rapid breathing (hyperventilating) feeling hot and sweaty feeling sick chest pain difficulty swallowing (dysphagia) diarrhoea trembling dizziness ringing in the ears (tinnitus) feeling faint They'll avoid situations that cause anxiety and may only leave the house with a friend or partner. They'll order groceries online rather than going to the supermarket. This change in behaviour is known as avoidance. ``` Cognitive symptoms may include fear that: a panic attack will make you look stupid or feel embarrassed in front of other people a panic attack will be life threatening – for example, you may be worried your heart will stop or you'll be unable to breathe you would be unable to escape from a place or situation if you were to have a panic attack you're losing your sanity you may lose control in public you may tremble and blush in front of people people may stare at you There are also psychological symptoms that aren't related to panic attacks, such as: feeling you would be unable to function or survive without the help of others a fear of being left alone in your house (monophobia) a general feeling of anxiety or dread Behavioural symptoms Symptoms of agoraphobia relating to behaviour include: avoiding situations that could lead to panic attacks, such as crowded places, public transport and queues being housebound – not being able to leave the house for long periods of time needing to be with someone you trust when going anywhere avoiding being far away from home Some people are able to force themselves to confront uncomfortable situations, but they feel considerable fear and anxiety while doing so.

Answer 182

A diagnosis of agoraphobia can usually be made if: you're anxious about being in a place or situation where escape or help may be difficult if you feel panicky or have a panic attack, such as in a crowd or on a bus you avoid situations described above, or endure them with extreme anxiety or the help of a companion there's no other underlying condition that may explain your symptoms Check TFTs

Answer 183

Antidepressant medications most commonly used to treat anxiety disorders are mainly selective serotonin reuptake inhibitors. Benzodiazepines, monoamine oxidase inhibitor, and tricyclic antidepressants are also sometimes prescribed for treatment of agoraphobia ``` CBT Applied relaxation Eye-movement desensitisation therapy Support groups Self-help groups ``` ``` SSRI SEs: feeling sick loss of sex drive (libido) blurred vision diarrhoea or constipation feeling agitated or shaky excessive sweating ```

Answer 184

Depression Reclusion Substance abuse disorder Resolution in half with treatment

Answer 185

Depression Reclusion Substance abuse disorder Resolution in half with treatment

Answer 186

Conversion and somatic symptom disorders are psychiatric conditions that fall under the somatic symptoms and related disorders category of the DSM-5. Somatic symptom and related disorders are those with distressing physical symptoms that are not fully explained by other medical, neurological, or psychiatric disorders (also known as somatisation). Conversion disorder is characterised by voluntary motor or sensory function deficits that suggest neurological or medical conditions but are rather associated with clinical findings that are not compatible with such conditions. Somatic symptom disorder is characterised by one or more somatic symptoms that are distressing or result in significant disruption of daily life. To meet DSM-5 criteria, these patients must have excessive thoughts, feelings, or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following: disproportionate and persistent thoughts about the seriousness of one’s symptoms; persistently high levels of anxiety about health or symptoms; excessive time or energy devoted to these symptoms or health concerns. Importantly, even if any one somatic symptom is not continuously present, the state of being symptomatic is persistent (typically more than 6 months). Somatic symptom and related disorders are psychiatric conditions where patients experience distressing physical symptoms that are not fully explained by other medical, neurological, or psychiatric disorders, as well as abnormal thoughts, feelings, and behaviours in response to these symptoms. They may result from psychological stress that is unconsciously (without awareness) expressed somatically, though the underlying cause is not fully understood. Risk factors include being female, having a history of abuse or adverse childhood events, and having personality traits of alexithymia (difficulty expressing emotions) or neuroticism. Symptoms that persist with an external focus of control, and without awareness of the psychological and stress-related interplay, can lead to considerable functional impairment and distress. Diagnosis is made by clinical interview, behavioural observation, physical examination suggestive of pseudoneurological causes, and tests to rule out medical or neurological causes. The diagnosis should not be made solely on the basis of medically unexplained symptoms; rather, it should be based on evidence from the clinical examination and the patient’s abnormal thoughts, feelings, and behaviours in response to the medically unexplained symptoms. Good doctor-patient relationships and validation of the patient's suffering are essential for effective management. Treatment includes cognitive behavioural therapy and avoiding unnecessary medicines, tests, and procedures. Diagnosis and treatment of associated comorbid psychiatric conditions benefit overall functioning and recovery. Long-term management involves interrupting perpetuating factors, maintaining the same doctor, and providing strategies for self-efficacy, distress tolerance, coping, and modulating the interaction of anxiety, stress, and physical symptoms.

Answer 187

M:F 1:3 Somatic symptom disorder 10% to 15% of primary care patients have multiple unexplained symptoms that are present for >2 years The prevalence of somatic symptom disorder is not known but may be around 5% to 7%. Conversion disorder 5-22 per 100k 10% of patients referred to general neurology outpatient clinics have purely medically unexplained symptoms; Psychogenic tremor, dystonia, myoclonus, and parkinsonism occurs in 2% to 3% of patients evaluated in specialty neurology clinics;

Answer 188

Chronic and/or acute intrapsychic (emotional/psychological) stress or conflict, in combination with either emotional processing deficits, avoidance tendencies, or social, cultural, or family taboos against emotional expression, seems to be important in the aetiology of somatisation. Societal attitudes in which people exhibiting psychological distress are less tolerated than those who are physically ill are also likely to reinforce somatisation. Cognitively, disturbances in attention and control through dissociation, misattribution, and misinterpretation probably contribute to both conversion and somatic symptom disorder symptoms.

Answer 189

``` STRONG Hx sex/physical abuse Hx unstable childhood Hx trauma related disorders Female Alexithyma (difficulty describing emotions) Neuroticism ``` WEAK Previously poor dr-pt relationships

Answer 190

``` COMMON Unconventional behaviour during Hx Emotional processing problems Recent life stressor Remote life stressor Multiple illness behaviours Unusual neurological deficit (ie not confined to dermatomal distribution) Give way weakness Inconsistent exam findings (ie leg weakness on testing an ambulatory pt) False sensory findings Distractable symptoms Inions ```

Answer 191

At initial presentation, all patients should have laboratory testing to rule out potential medical or neurological conditions. Repeat laboratory evaluations may be necessary when new symptoms arise. In established conversion disorder, it is not necessary to repeat and exhaust all medical evaluations when there is clear evidence of pseudoneurological disorders (and no other indication of neurological conditions) on neurological examination. Continuous video-EEG monitoring can be useful in establishing a psychogenic non-epileptic seizures diagnosis when typical spells are captured. standardised personality testing - mental illness trait, personality disorder trait, hypochondriasis, depression, hysteria, anxiety, somatisation, pain disorder, or health concern

Answer 192

Eclectic psychotherapy - Includes a combination of cognitive behavioural therapy (CBT), mindfulness, and/or short-term dynamic psychotherapy, interpersonal psychotherapy, re-attribution training, and general psychotherapy. CBT for this group involves reducing physiological arousal through relaxation techniques; enhancing activity regulation through increased exercise, and pleasurable and meaningful activities; pacing activities; increasing awareness of emotions; modifying dysfunctional beliefs; enhancing communication of thoughts and emotions; and reducing spousal reinforcement of illness behaviour. Psychiatric consultation - Involves regular, rather than as-needed, scheduling of appointments; conducting brief physical examinations focusing on areas of discomfort at each visit; avoiding unnecessary diagnostic procedures, invasive treatments, and hospital admissions; and avoiding explanations such as "Your symptoms are all in your head" Graded physical exercise Biofeedback training ``` Antidepressant: Duloxetine Sertraline Citalopram Fluoxetine ``` SNRIs, nortriptyline, and amitriptyline are used as first line in order to target chronic pain symptoms. SSRIs include sertraline, citalopram, fluoxetine, paroxetine, escitalopram, and fluvoxamine. SNRIs include venlafaxine, desvenlafaxine, and duloxetine. TCAs include nortriptyline, amitriptyline, desipramine, imipramine, and doxepin. Doses should be started low and increased gradually according to response.

Answer 193

Depression Anxiety Suicide Substance abuse

Answer 194

Conversion disorder Between 50% and 90% of patients with conversion disorder exhibit short-term resolution of symptoms after reassurance, but up to 25% of these responders relapse or develop new conversion symptoms over time. Somatic symptom disorder Reported remission rates range from very low (<10%) to a 50% recovery within 1 year.

Answer 195

Conversion and somatic symptom disorders

Answer 196

Conversion and somatic symptom disorders

Answer 197

Post-traumatic stress disorder (PTSD) may develop following exposure to 1 or more traumatic events such as deliberate acts of interpersonal violence, severe accidents, disasters, or military action. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), it is characterised by 4 types of symptoms: intrusions (e.g., flashbacks, intrusive images and sensory impressions, dreams/nightmares); avoidance (e.g., avoiding people, situations, or circumstances resembling or associated with the event); negative alterations in mood and cognition (e.g., feeling alienated from others, constricted affect, diminished interest in significant activities, distorted negative beliefs about oneself or the world, and inability to remember key features of the traumatic event); and alterations in arousal or reactivity (e.g., hypervigilance for threat, exaggerated startle response, irritability, difficulty concentrating, and sleep problems). These symptoms must impair function for a diagnosis to be made. SUMMARY Disorder that may develop (either immediately or delayed) following exposure to a stressful event or situation of an exceptionally threatening or catastrophic nature. According to DSM-5, it is characterised by 4 groups of symptoms: intrusion symptoms, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. These symptoms must impair function for a diagnosis to be made. More often than not, presentation is comorbid with problems such as depression, anxiety, anger, and substance misuse. Clinicians should ask whether patients presenting with such symptoms have suffered a traumatic experience. Assessment should cover physical, psychological, and social needs, and an assessment of risk: this can be facilitated by the use of screening questionnaires and a clinical interview schedule. Trauma-focused psychological treatments are the most effective treatment. Pharmacotherapy may be used in patients who do not respond to, cannot tolerate, do not want, or do not have access to psychological therapies.

Answer 198

In the UK, although exposure to potentially traumatic experiences since the age of 16 was reported in only 33% of adults, current PTSD was reported in 3%. Certain groups are more likely to be exposed to PT Es: these include military personnel, emergency-service workers, police, and refugees.

Answer 199

People who are at risk of PTSD include those who have been exposed to, or have witnessed, extreme traumatic stressors, such as intentional acts of violence, physical and sexual abuse, accidents, disaster, or military action. People who have experienced threat to their own life or the life of others while in medical care, such as during anaesthesia, complications during childbirth, or as a result of medical negligence, are also at risk. Emotional processing theory: implicates complex fear structures, which exist in memory and which produce cognitive, behavioural, and physiological reactions when activated. It is argued that in PTSD, these have become pathological. Alterations in beliefs about the world and the self, brought about by difficulties in processing information about the traumatic event, lead to misinterpretation of benign stimuli as dangerous and of the self as being incompetent. Dual representation theory: based on research into memory processing, and argues the existence of different types of memory, namely verbally accessible memories (VAMs) and situationally accessible memories (SAMs). Whereas VAMs are easily recalled, SAMs remain unconscious until triggered, whereupon they give rise to symptoms such as dreams and flashbacks, during which the emotions felt during the traumatic event are re-experienced with the same degree of intensity. Cognitive model of PTSD: argues that negative appraisals of the traumatic event lead to the development of views of the world as a dangerous place and of the self as incompetent. This leads to a sense of current threat in which situations are misinterpreted as threatening.

Answer 200

``` STRONG Serious accident Witness of school violence / domestic Natural disaster Terrorist attack Torture Combat exposure Traumatic brain injury Sudden death of loved one Molestation Rape Victimisation by attacker Previous trauma Multiple major life stressors Low social support Hx mental disorder Hx of drug and alcohol abuse ``` WEAK Female Younger age

Answer 201

4 groups of symptoms: intrusion symptoms, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. ``` Exposure and response to trauma Intrusion Sx (re-experiencing) (e.g., flashbacks, intrusive images and sensory impressions, dreams/nightmares, emotional and physiological reactivity to internal and external cues) Avoidance Sx - persistent effortful avoidance of reminders of the trauma. Negative alterations in cognition/mood - diminished ability to experience positive feelings and feelings of closeness to others, persistent negative/distorted beliefs, distorted ideas of blame, loss of interest in significant activities, and inability to recall key aspects of the traumatic event. Alterations in arousal + reactivity - hypervigilance for threat, exaggerated startle response, irritability, angry outbursts, self-destructive or reckless behaviours, difficulty concentrating, and sleep problems. ``` OTHER COMMON Depression Alchohol/substance misuse Anxiety

Answer 202

PTSD Checklist for DSMV IES - Impact of event scale TSQ - Trauma screening questionnaire PSSI - PTSD symptom scale interview version

Answer 203

Symptoms <3 months = watch and F/U in one month SEVERE Trauma focussed CBT Eye-movement desensitisation and reprocessing - Procedures are based on stimulating the person's own information processing in order to help integrate the targeted event as an adaptive contextualised memory. People are made ready to attend to the memory and associations while their attention is also engaged by a bilateral physical stimulation (e.g., eye movements, taps, or tones). Antidepressants are effective in reducing severity of the core symptoms of PTSD as well as associated depression and disability. However, owing to the small effect sizes in systematic reviews, pharmacotherapy should be considered only after trauma-focused psychological treatment has been initiated, or failure to adhere/respond Sertraline, fluoxetine, amytriptyline If there is a response to drug treatment, the drug should be continued for at least 12 months before gradual withdrawal, usually over a 4-week period, although some patients may require a longer period of withdrawal. Non-trauma focussed CBT

Answer 204

``` Increase in distress due to exposure therapy Anxiety Depression Psychosis Substance misuse Suicide ```

Answer 205

Whereas most people who go through traumatic events experience a brief acute response to the stressful situation and never develop an enduring pathological reaction, a smaller proportion of people will develop PTSD, either alone or complicated with comorbid disorders such as depression, generalised anxiety disorder, or substance abuse. The average duration of symptoms, if treated, is 36 months, and the average duration of symptoms among those untreated is 64 months. Moreover, while almost 50% experience significant reduction in symptoms, more than one third of people never fully remit.

Answer 206

Post-traumatic stress disorder

Answer 207

Post-traumatic stress disorder

Answer 208

Bipolar disorder, previously termed manic depression, is a psychiatric diagnosis characterised by abnormally elevated or irritable mood episode(s) accompanied by disruptive symptoms of distractibility, indiscretions, grandiosity, flight of ideas, hyperactivity, decreased need for sleep, and talkativeness. Manic episodes include a clustering of these symptoms over at least a period of 1 week, and are more disruptive than hypomania (milder symptoms, >4 days' duration). It is marked by alternating mood elevation (mania or hypomania) and depression. A recurrent and sometimes chronic mental illness marked by alternating periods of abnormal mood elevation and depression associated with a change or impairment in functioning. The long-term course of illness is characterised by a predominance of depression, although a history of at least one manic, hypomanic, or mixed episode is required to make the diagnosis of a bipolar disorder. Diagnosis is based on interviews with the patient and family, using diagnostic criteria for bipolar disorder. Misdiagnosis of bipolar disorder is common, with unipolar major depressive disorder the most frequent diagnostic error made. The management of acute mania requires the use of mood stabilisers or atypical antipsychotics, as monotherapy or in combination. There are fewer approved treatment options for acute bipolar depression; traditional antidepressants are not indicated. Bipolar disorder requires individualising a long-term management plan that includes maintenance medication(s), adjunctive psychosocial therapies, and careful monitoring for any treatment-emergent complications.

Answer 209

Bipolar disorder is the sixth leading cause of disability in the developed world among those between the ages of 19 and 45 years. The total lifetime cost of illness in the US is estimated at 202 billion US dollars. 1% lifetime prevalence Thirty-five percent of the patients were symptomatic for >10 years before being accurately diagnosed, with women significantly more likely than men to be misdiagnosed. Up to 50% of all people with bipolar disorder have been estimated to make at least 1 suicide attempt in their lifetime, with 10% to 15% of untreated patients with bipolar disorder completing suicide. The lifetime prevalence of any substance misuse disorder among patients with bipolar I disorder is 61%, and among those with bipolar II disorder is 48%; these rates are higher than those observed among patients with schizophrenia (47%), obsessive-compulsive disorder (33%), and major depressive disorder (27%).

Answer 210

The exact aetiology of bipolar disorder is unknown, although the risk for disease is thought to be influenced by several genes. Family and twin studies substantiate the importance of genetic factors influencing a person's risk for bipolar disorder, with environmental stressors or triggers being likely to contribute to the phenotypic expression of the underlying mood disorder.

Answer 211

``` STRONG FHx Onset of mood disorder prior to 20yrs old Stressful life event Hx depression Lifetime history substance misuse Presence of an anxiety disorder ``` WEAK Obesity CV disease

Answer 212

``` COMMON Major depress episode(s) Episode(s) of manic or mixed episodes Episode(s) of hypomania Grandiosity Decreased sleep Talkative Flight of ideas/racing thoughts Distractibility Increased goal directed activity Excessive involvement in pleasurable activities that have a high potential for adverse consequences Functional impairment No substance misuse No underlying medical cause Not due to somatic antidepressant ```

Answer 213

Bipolarity index Young mania rating scale Patient Health Questionnaire-9 PRIME-MD - primary care evaluation of mental disorders FBC TFTs Vit D Lipid derangements often found in patients with BPD MRI - Test should not routinely be ordered except in the case of new onset of mania or atypical presentations, to rule out an organic aetiology, such as brain tumour or multiple sclerosis.

Answer 214

IF AGITATED IM neuroleptic / BDZ - olanzipine/aripiprazole/Lorazepam ORAL MONOTHERAPY = MOOD STABILISER OR ATYPICAL ANTIPSYCHOTIC Lithium / Carbamazepine / risperidone / olanzipine / quetiapine For patients who do not respond to monotherapy, consideration of dose optimisation and medication adherence is recommended. However, switching to an alternative mood stabiliser or atypical antipsychotic agent should be tried if the original agent is ineffective. CAN ADD TYPICAL ANTIPSYCHOTIC IF FAILS EG haloperidol Patients with symptoms of mania who have not responded to several trials of medications should be considered candidates for either clozapine or ECT. The addition of psychosocial interventions for bipolar depression has been associated with higher recovery rates at 1 year as well as shorter times to recovery.

Answer 215

``` Valproate SE hyperammonaemic encephalopathy Lamitrigine induced rash Obesity SE Lithium nephrotoxicity Lithium induced hypothyroidism Metabolic syndrome Suicide Disability Lithium toxicity SCD Atypical SE - Extra-pyrimidal/tardive dyskinesia Valproate induced hepatitis Blood dycrasias due to carbemazepine (Aplastic anaemia and agranulocytosis) ```

Answer 216

Likelihood of recurrence is almost certain, as the vast majority of patients have more than 1 lifetime episode. Although considerable variability exists regarding relapses across individuals with bipolar disorder, it is generally believed and supported by the evidence that, over time, episodes become more frequent and that the euthymic intervals become shorter in between episodes. Subsyndromal symptoms may be chronic for some patients with bipolar disorder. Manic episodes typically have an abrupt onset, developing over a few days, while depressive episodes usually develop more gradually. With treatment, episodes of mania, depression, or mixed states last for approximately 3 months. Mortality is higher among patients with bipolar disorder when compared with the general population. The standardised mortality ratio for bipolar disorder due to cardiovascular disease is reported to range between 1.2 and 3.0, while the standardised mortality ratio for suicide is between 14.0 and 23.4.

Answer 217

Bipolar disorder in adults

Answer 218

Bipolar disorder in adults

Answer 219

Bipolar disorder in adults

Answer 220

Anorexia nervosa (AN) is an eating disorder characterised by restriction of caloric intake leading to low body weight, an intense fear of gaining weight, and a body image disturbance. Patients with anorexia nervosa (AN) typically have low body weight, intense fear of gaining weight, and a body image disturbance. While more often detected in women, cases of AN in young men may be under-represented. Weight restoration with re-feeding techniques is essential for prevention of sequelae, such as heart failure, fertility problems, and osteoporosis. Patients with AN are often identified through family referral and the patient's physical complaints. Early intervention is key in order to prevent long-term psychiatric and physical complications of AN. Among psychiatric illnesses, AN has one of the highest premature mortality rates (with a risk of premature death of approximately 5-fold greater than that of peers).

Answer 221

According to strict diagnostic criteria, about 0.3% of people in westernised countries, with about 0.5% to 1% of college-aged women, are affected. It is estimated that 3 in 10 patients are male, but many males may not present for treatment; thus, about 90% of patients diagnosed are female White women are more likely to be diagnosed with AN than women from ethnic minority groups.

Answer 222

No single aetiology has been identified for AN. Multiple biological, psychological, and social factors likely contribute to its development and persistence.

Answer 223

``` STRONG Female Adolescence and puberty Obsessive/perfectionist traits Exposure to western media Genetic influence ``` WEAK Middle / upper socioeconomic classes

Answer 224

``` COMMON Significantly low body weight Fear of gaining weight Disturbed body image Calorie restriction Binge eating/purging Misuse of laxatives, diuretics or diet pills Amenorrhoea Decreased subcutaneous fat General weakness Poor concentration Fatigue Orthostatic hypotension Non-specific GI Sx Hair/skin/nail changes Cardiac Sx Dependent oedema Osteopenia/porosis ```

Answer 225

The key elements of the DSM-5 diagnostic criteria for AN are as follows: A. Restriction of energy intake relative to requirements, leading to a significantly low weight in the context of age, sex, developmental trajectory, and physical health B. Intense fear of gaining weight or persistent behaviour that interferes with weight gain C. Disturbance in body image. Specific subtype: Restricting subtype: no episodes of binge eating or purging in the preceding 3 months; weight loss has been achieved by dieting, fasting, and/or excessive exercise Binge-eating/purging subtype: recurrent episodes of binge eating or purging behaviour (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas) in the preceding 3 months. Specific level of severity for adults. The level of severity can be increased based on other indicators such as medical instability and illness duration: Mild: BMI ≥17 kg/m² Moderate: BMI 16-16.99 kg/m² Severe: BMI 15-15.99 kg/m² Extreme: BMI <15 kg/m². CHECK: FBC anaemia U+E - metabolic alkalosis and hypokalaemia (if vomiting is present); metabolic acidosis, hyponatraemia and hypokalaemia (if laxative use is present), hypomagnesaemia, hypophosphataemia, hypocalcaemia, hypoglycaemia, elevated urea levels TFTs LFTs Urinalysis - low specific gravity may indicate consumption of large quantities of free water; ketonuria may indicate significant semi-starvation

Answer 226

Structured eating plan with oral nutrition Low weight patients who are not at significant risk of developing re-feeding syndrome will commonly begin therapeutic feeding at caloric prescriptions of 1500-1800 kcal/day. Caloric prescriptions may increase by 400 kcal/day every 48-72 hours if patients tolerate prior caloric level, in order to achieve consistent weight change approximating 1-2 kg/week for inpatients (with 0.5-1 kg/week more common in outpatient programmes). Peak caloric requirements in treatment programmes that aim to help patients achieve full weight restoration reach >3500 kcal/day for females and >4000 kcal/day for males. Meal plans may include liquid supplements in addition to solid foods. Vitamins and minerals (e.g., multivitamin, phosphorus, magnesium, and calcium) should be given until the patient’s diet contains enough to meet his or her dietary reference values. Thiamine supplementation should be considered. Psychotherapy UK-based guidance from the National Institute for Health and Care Excellence (NICE) recommends AN-focused family therapy for children and young people with AN delivered as single-family therapy or a combination of single- and multi-family therapy (with children and young people offered the option to have some sessions separately from their family or carers). REFEEDING May need potassium/magnesium/sodium/calcium replacement Monitor fluid intake Hospital care may be either medical or psychiatric depending on the degree and severity of physical symptoms, and the experience of the psychiatric unit in managing malnutrition. [36] Inpatient care is generally recommended for patients with exceedingly low weight (e.g., <75% expected), precipitous loss of weight, and/or evidence of medical complications of illness, including significant bradycardia, hypotension, or hypothermia, laboratory abnormalities (e.g., electrolyte disturbance, hypoglycaemia), and psychiatric instability including suicidality. Can try SSRIs or olanzipine

Answer 227

The prognosis for AN is best when identification and treatment begin early in the illness course, and when full weight restoration is achieved. Recovery-focused treatment is always recommended, and recovery does occur, even among patients who have been ill for an extended period, but younger patients are thought to have the best prognosis. Follow-up studies suggest that approximately 75% of adolescent patients with AN achieve full recovery, although time to recovery may be 3-5 years. Mortality associated with AN is high, estimated at 5% per decade of illness. Among psychiatric illnesses, AN has one of the highest premature mortality rates (with a risk of premature death of approximately 5-fold greater than that of peers). Deaths are due primarily to medical complications or suicide.

Answer 228

``` Peripheral oedema secondary to refeeding Refeeding syndrome Anaemia Hypophoshataemia Thiamine deficiency 2nd to refeeding Primary amenorrhoea Infertility Osteopenia Osteoporosis Growth retardation Skeletal fractures Lip/mous fissures Glossitis Bleeding gums Congestive heart failure Slowed GI motility Acute+chronic renal failure Pregnancy complications ```

Answer 229

Anorexia nervosa

Answer 230

Anorexia nervosa

Answer 231

Schizoaffective disorder is an illness defined by a course that combines significant affective and psychotic symptoms. The Diagnostic and statistical manual of mental disorders (DSM) definition requires the presence of schizophrenia symptoms concurrent with the mood symptoms (depression or mania), and lasting for a considerable part of a 1-month period. Schizoaffective disorder is further classified as manic type (when manic symptoms are prominent) or depressive type (when only schizophrenia and major depressive symptoms have been present). Schizoaffective disorder has features of both schizophrenia and mood disorders. The lifetime prevalence is in the range of 0.32% to 1.1%. The depressive type of schizoaffective disorder is more common in older patients, whereas the bipolar type is more common in younger patients. Patients have a better prognosis than patients with schizophrenia but a worse prognosis than patients with mood disorder. Patients tend to have a non-deteriorating course and better response to mood stabiliser medications than patients with schizophrenia. Patients with schizoaffective disorder are a heterogeneous group with a variable predominance of schizophrenia and affective disorder symptoms.

Answer 232

Schizoaffective disorder is estimated to be less common than schizophrenia. Age of onset: 30% of cases have their onset under the age of 25 years, 30% between ages 25 and 35 years, and 30% above the age of 35 years. Gender distribution: appears to occur more frequently in women. In regional studies, lifetime prevalence for schizoaffective disorder varies from 0.32% to 1.1%.

Answer 233

Most aetiopathological studies cluster schizoaffective disorder together with schizophrenia or bipolar disorder. As such, there is no specific pathophysiology that is ascribed exclusively to this disorder. Genetic data suggest that chromosome 1q42 (near DISC1 gene location) and the BDNF gene may be associated with schizoaffective disorder.

Answer 234

STRONG FHx Substance abuse WEAK Age of father at patients birth Psychological stress Environment

Answer 235

COMMON +ve Sx: Such symptoms include hallucinations, delusional ideation, thought disorder, and bizarre behaviour. -ve Sx: Examples of negative symptoms include anhedonia, amotivation, social isolation, or flat affect. Disorder of perceptions Delusions- Common delusional themes in schizoaffective disorder, as in schizophrenia, are persecutory, grandiose, nihilistic (also common in depression), religious, and somatic. Disturbance in emotion Disorder of stream and form of thought Cognitive abnormalities Deficit Sx - asociality (withdrawal from interpersonal interactions), avolition (decrease in interests and activities), affective blunting, alogia (quantitative and qualitative decrease in speech), and anhedonia (lack of enjoyment in any previously pleasurable activities). Neurological deficit FHx Disorders of behaviour - mannerisms (goal-directed behaviour carried out in a stilted fashion), stereotypies (uniformly repetitive movements), parakinesis (e.g., grimacing, twitching, and jerking), echopraxia (repetition of a movement seen in others), automatic obedience (automatic execution of directions), and waxy flexibility (ability to maintain imposed positions for long periods of time). Catatonia can be seen with psychomotor agitation or retardation.

Answer 236

Urine drug screen STI screen FBC TFTs CRITERIA DSMV Schizoaffective disorder debut has an uninterrupted period of illness, during which there is an episode of mood disorder (manic or major depressive disorder) concurrent with a schizophrenia episode characterised by 2 or more of the following symptoms present for a considerable part of a 1-month period: delusions hallucinations disorganised speech (e.g., frequent derailment or incoherence) grossly disorganised or catatonic behaviour negative symptoms (i.e., affective flattening, alogia, or avolition). During this time, there should be a period of at least 2 weeks with delusions and hallucinations, in the absence of prominent mood symptoms during the lifetime duration of illness. Mood symptoms have been present for the majority of the total duration of the active and residual period of illness. Other possible etiologies such as substances (e.g., drug abuse, medication) or general medical conditions have been ruled out. Specify whether bipolar type (if manic episode is part of the presentation; major depressive episodes may also occur) or depressive type (if only major depressive episodes are part of the presentation). Specify if: with catatonia. Specify if: (the following course specifiers are only to be used after a 1-year duration of the disorder and if they are not in contradiction to the diagnostic course criteria) First episode, currently in acute episode First episode, currently in partial remission First episode, currently in full remission Multiple episode, currently in full episode Multiple episode, currently in partial remission Multiple episode, currently in full remission Continuous Unspecified.

Answer 237

ACUTE Start or review oral typical/a antipsychotic MAY NEED IM Antipsychotic: Olanzipine / aripiprazole / ziprasidone +/- Lorazepam anxiolytic MULTIPLE EPISODE DISORDER 1st line: atypical antipsychotic The benefits of these agents over older antipsychotics, in terms of decreased risk for extrapyramidal adverse effects and tardive dyskinesia, need to be balanced on an individual basis against the increased risk for weight gain and metabolic syndrome, which is especially seen with olanzapine. 2week minimum trial length Mood stabiliser lithium can be given alongside atypical if refractory CBT Social skill training 2 failures of treatment -> try clozapine (worry of agranulocytosis though) Can try typical antipsychotic if all else fails: eg haloperidol or fluphenazine - The efficacy of these medications is well established, but they are not generally recommended as initial treatment because they carry a higher likelihood of tardive dyskinesia and worsening of negative symptoms.

Answer 238

``` Orthostatic hypotension (SE) Dystonia (Parenteral diphenhydramine or benztropine produces reversal of dystonia in minutes.) Neuroleptic malignant syndrome Suicide Substance abuse Tardive dyskinesia Parkinsonism Weight gain (atypical) Metabolic (atypical) Anticholinergic Prolactin elevation Prolonged QT Agranulocytosis ```

Answer 239

The prognosis of patients with schizoaffective disorder, measured in terms of overall poor outcome and parameters such as work functioning and cognitive impairments, appears to be better than the prognosis of patients with schizophrenia but worse than the prognosis of patients with mood disorders. As in schizophrenia, predictors of poor prognosis include an insidious course, prior history of poor functioning, a family history of schizophrenia, predominant psychotic symptoms and negative symptoms, poor recovery in between episodes, mood-incongruent psychotic symptoms, and lack of clear precipitants.

Answer 240

Schizoaffective disorder

Answer 241

Schizoaffective disorder

Answer 242

Alcohol-use disorder is a term used to refer to the misuse of alcohol. Several specifically defined conditions better categorise patterns of alcohol misuse. It is characterised by increased tolerance to the effects of alcohol, the presence of characteristic withdrawal signs and symptoms, and impaired control over the quantity and frequency of drinking. Alcohol-use disorder can be associated with a variety of medical and psychiatric sequelae. Alcohol-use disorder is diagnosed when, over a 12-month period, the patient's drinking has caused clinically significant impairment or distress. Alcohol-use disorder is a common psychiatric disorder that is multifactorial in aetiology, chronic in nature, and is associated with a wide variety of medical and psychiatric sequelae. Tolerance, withdrawal, impaired control of drinking behaviour, and continued alcohol use despite adverse consequences are some important features of alcohol dependence. Alcohol withdrawal syndrome can follow cessation or reduction in alcohol consumption. Withdrawal can be a serious medical condition. It is best monitored by use of a structured instrument: the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar). Benzodiazepines are the definitive medical treatment. Binge-drinking, alcohol abuse, and mild alcohol dependence may be addressed by brief physician-based interventions, or psychological interventions such as cognitive behavioural therapy. Moderate or severe alcohol-use disorder requires multi-modal treatment. Detoxification in an inpatient or outpatient setting may be necessary. The goal of detoxification is to minimise withdrawal symptoms and to facilitate entry into an ongoing, multi-modal treatment programme directed towards assisting the patient in maintaining abstinence. Medications, including naltrexone, nalmefene, acamprosate, and disulfiram, can be successfully utilised for selected patients to improve their chances of maintaining abstinence.

Answer 243

Alcohol-use disorder is a common psychiatric disorder with lifetime prevalence estimates of 7% to 10% in most Western countries. M:F 2:1 In primary care settings, the prevalence of alcohol-use disorders ranges from 20% to 36%. It is estimated that alcohol causes a significant global disease mortality burden, accounting for 3.2% of global deaths.

Answer 244

Alcohol-use disorder is a chronic illness with a multifactorial aetiology, combining several components, genetic as well as social, psychological, and environmental. Approximately 50% of the risk of developing alcohol-use disorder is genetically determined, but the influence of genes is complex, as there are genes that increase risk and genes that are protective. Alcohol-use disorder is frequently associated with psychiatric disorders, especially affective disorders, anxiety disorders, post-traumatic stress disorder, and schizophrenia. Alcohol affects many brain neurotransmitters and their receptors, including dopamine, gamma-aminobutyric acid, glutamate, serotonin, adenosine, noradrenaline (norepinephrine), and opioid peptides. The clinical course of patients with addictive disorders is characterised by phases of repeated intoxication, withdrawal, and abstinence, with the disorder progressing from impulsivity to compulsivity. Chronic exposure of the brain to alcohol is thought to result in long-term adaptive changes that initially produce increased reinforcement for alcohol use, and over time progress to withdrawal and negative affective states, so that regular alcohol use is required to feel normal.

Answer 245

STRONG FHx Antisocial behaviour High trait anxiety level WEAK Lack of facial flushing on exposure to alcohol Low responsively to effects of alcohol Hx gastric bypass

Answer 246

COMMON RFs Withdrawal Sx: Increased autonomic activity, agitation, and nervousness are common symptoms. Generalised seizures and a confusional state (delirium) are seen in more severe cases of alcohol withdrawal. Tolerance Sx of liver disease Nicotine dependence Social, economic,legal or psychological problems Gastritis/pancreaitis - N+V, abdo pain, haematemesis Muscle cramps, pain, tenderness, altered sensory perception Hypertension and tachycardia Possible skin manifestations of alcoholism include increased superficial cutaneous vasculature, urticarial reactions, porphyria cutanea tarda, flushing, cutaneous stigmata of cirrhosis, psoriasis, pruritus, seborrhoeic dermatitis, and rosacea. Impaired nutritional status Dental hygeine Broad based gait

Answer 247

Diagnostic interview using DSMV criteria OR A QUESTIONNAIRE: AUDIT - Alcohol Use Disorders Identification Test OR Severity of alcohol dependence questionnaire Alcohol level (breath/blood) (CIWA-Ar) - The revised Clinical Institute Withdrawal Assessment for Alcohol

Answer 248

(CIWA-Ar) - The revised Clinical Institute Withdrawal Assessment for Alcohol SCORE >8 = need BDZ - May need inpatient/outpatient speciality Rx Mild: Motivational interviewing, cognitive-behavioural therapy with 12 steps, cognitive-behavioural therapy with aftercare, multidimensional family therapy Mod-Severe Motivational interviewing CBT Alcoholics Anonymous Frequent relapse = pharmacotherapy Naltrexone - opioid antagonist Acamprosate - maintains abstinence Disulfiram - blocks metabolism Nalmefene - mu opioid antagonist

Answer 249

``` Mallory Weiss Delerium tremens Seizure Alcoholic liver disease Cirrhosis Nutritional disorders Cardiomyopathy Wernick-korsakoff syndrome ```

Answer 250

Alcohol-use disorder tends to run a chronic course. While treatment does impact the condition positively, relapse is common, particularly in the first 12 months after treatment initiation. Medication treatments are relatively under-utilised for alcohol-use disorders, despite their shown efficacy.

Answer 251

Bulimia nervosa is an eating disorder characterised by recurrent episodes of binge eating, followed by behaviours aimed at compensating for the binge. Binge-eating episodes are characterised by eating an amount of food that is definitely larger than most people would eat (e.g., at least twice the normal amount of food ingested) over a discrete period of time (it must be ingested more quickly than normally). Binges are accompanied by a sense of lack of control over eating during the episode. Recurrent inappropriate compensatory behaviours occur in order to prevent weight gain. These behaviours include self-induced vomiting; fasting; excessive exercise; and misuse of laxatives, diuretics, enemas, or other medication. Binge-eating episodes typically occur, on average, at least weekly for 3 months. An eating disorder, characterised by severe preoccupation about weight and body shape. Includes recurrent episodes of binge eating with compensatory mechanisms, such as self-induced vomiting, to prevent weight gain. Most common in women in their 20s and 30s. Patients usually appear physically normal, although they may have low self-esteem and depressive thoughts, as well as lack of confidence. Parotid hypertrophy and erosion of the teeth are the most common physical signs and may prompt diagnosis. Cognitive behavioural therapy (CBT) is considered optimal primary treatment for bulimia, but it may not always be available. Selective serotonin-reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) may be used adjunctively to CBT, or as an alternative when CBT is not available. Treatment of comorbid psychiatric disorders, such as major depressive disorder and obsessive-compulsive disorder, is necessary to optimise the chance of recovery from bulimia nervosa. SSRIs are effective in additional treatment of comorbid psychiatric disease.

Answer 252

Lifetime prevalence of DSM-5-defined bulimia nervosa by age 20 is 2.6% in women. W>B

Answer 253

The aetiology of bulimia nervosa is uncertain. A biopsychosocial theory of causation posits a combination of coexisting biological (genetic abnormalities in receptors or neurotransmitters), psychological, and social factors. Risk factors that are strongly associated with bulimia nervosa include female sex; perfectionism; body dissatisfaction; impulsivity; history of sexual abuse; family history of alcoholism, depression, or eating disorder; past obesity; and exposure to media pressure. An association with urbanisation has been reported.

Answer 254

``` STRONG Female Personality disorder Body image dissatisfaction Hx sex abuse Impulsivity FHx alcoholism FHx depression FHx eating disorder Childhood obesity Exposure to media Early onset puberty ``` WEAK Urbanisation FHx obesity

Answer 255

Recurrent binge eating Recurrent compensatory behaviour - There must always be some form of compensatory behaviour to attempt to burn off calories. This may be purging (vomiting, laxatives, enemas, suppositories) or non-purging (exercise, fasting). Occurs, on average, at least once a week for 3 months. ``` Eating disturbance not exclusively anorexia Depression Low self esteem Concern about body image Dental erosion Parotid hypertrophy Russels sign - Scarring over the dorsum of the hands. Arrythmia Menstrual irregularity Drug seeking behaviours Self injurious behaviour Insulin misuse GI Sx - oesophageal reflux, diarrhoea, constipation, and abdominal pain Hx dieting Marked fluctuations in weight ``` UNCOMMON Use of ipecac Needle marks on skin Vomiting in pregnancy

Answer 256

U+E - may show hypokalaemia or alkalosis Serum Creatinine - may be elevated Magnesium - may be low Urine preg test LFTs - Drug overdose, alcohol ingestion, or excess exercise may elevate aminotransferases. Serum creatine kinase - Drug overdose, alcohol ingestion, or excess exercise may elevate CK. FBC - patients may self-phlebotomise as a form of purging, but rarely give this history. Anaemia and the presence of needle marks may be the only clues Urinalysis - may show ketones CONSIDER ECG B12 DEXA

Answer 257

1. CBT / CBT self-help +/- nutritional and meal support Meal support means that a therapist actively supports the patient at mealtimes regarding their concerns, feelings, habits, and beliefs about eating. +/- SSRI/SNRI Fluoxetin/sertraline OR Venlafaxine These are used to temporarily reduce the frequency of binge eating and purging. Only 1 to 2 weeks of medication should be prescribed. 2. Interpersonal Therapy Core dysfunctional thoughts, attitudes, motives, conflicts, and feelings should be addressed. If the patient presents with physical symptoms such as loss of consciousness, syncope, and seizures, referral for emergency department assessment is advised. If the patient has diabetes, referral to an endocrinologist is recommended. Alcoholism or other substance abuse, borderline personality disorder, or ongoing self-injurious behaviour also indicates the need for immediate specialised psychiatric or psychological referral.

Answer 258

Bulimia nervosa has an average onset at an age of about 18 years, but bingeing and purging to a lesser degree is much more common. Many, if not most patients, who meet the diagnostic criteria for bulimia do not access medical help. Of those who do, 45% to 75% recover completely, 27% improve considerably, and 23% have a chronic course. The crude mortality rate is approximately 0.32% to 3.9%. Most patients with bulimia nervosa continue an active life despite the disorder.

Answer 259

``` Volume depletion Hypomagnesaemia Tooth erosion Pancreatitis Ipecac related cardiomyopathy Hypokalaemia Cardiac dysrythmia Haematemesis Oesophageal rupture Death Suicide ```

Answer 260

Bulimia nervosa

Answer 261

Bulimia nervosa

Answer 262

Bulimia nervosa

Answer 263

Personality disorders refer to enduring patterns of thinking and feeling about oneself and others that significantly and adversely affect how an individual functions in the various aspects of life. In the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), [1] the personality disorders fall into 10 distinct types: paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive. None of the criteria for personality disorders has changed in the DSM-5 compared with the previous edition, DSM-IV. Relatively common, chronic pattern of perceptual and behavioural abnormalities. These manifest as problems in at least two of the following domains: cognitive-perceptual, affect regulation, interpersonal functioning, or impulse control. Onset of symptoms in childhood/adolescence with stability over time. Typical presentation involves comorbid disorders (more than one personality disorder or additional diagnoses of depression, anxiety, somatoform, or substance abuse disorder). Ongoing relationship with primary care physician is essential but may be challenging to maintain. Potential for self-harm must be monitored. There is also potential for social withdrawal. Psychotherapy is indicated in most cases. Selective use of pharmacotherapy can provide added benefit.

Answer 264

Prevalence rates for DSM-IV personality disorders range from 9% to 11.2% Schizoid personality disorder was found to be more common in men, with schizotypal personality disorder diagnosed equally between men and women. Prevalence of antisocial personality disorder appears to decline with increasing age.

Answer 265

There is evidence for both environmental and genetic effects on the development of personality disorders; however, the relative contribution of each is variable. Similarly, an investigation of exposure to antenatal adversities (i.e., tobacco use, alcohol consumption, anxiety, and depression) found that exposure to increased stress in utero was associated with borderline personality disorder in children 11 to 12 years later. Environmental factors that have been linked to development of personality disorders include: childhood maltreatment, particularly a history of childhood physical abuse; sexual abuse; and neglect.

Answer 266

``` STRONG Hx abuse FHx schizophrenia Negative parenting interactions Emotional/disruptive disorder in childhood ```

Answer 267

Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest; More common in men; Deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure; Impulsiveness or failure to plan ahead; Irritability and aggressiveness, as indicated by repeated physical fights or assaults; Reckless disregard for safety of self or others; Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations; Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

Answer 268

Clinica interview - symptoms dating from adolescence/early adulthood; not occurring solely in the presence of another disorder such as depression or anxiety; significant difficulties in interpersonal interactions may lead to suspected diagnosis of personality disorder CONSIDER Suicide risk screening Standardised assessment of personality abbreviated scale - SAPAS Structured clinical interview for DSM-IV axis 2 personality disorders Urine drug screen MRI/CT brain (ie potential picks Sx) Depression screen - mood disorder questionnaire

Answer 269

AT RISK OF SELF HARM ?Hospitalisation - May need referral for substance abuse assessment CLUSTER A - Odd/eccentric IE paranoid/schizoid/schizotypal Communication that is straightforward with an unintrusive style is recommended in this group. The physician should display interest in those concerns that the patient is willing to share. Low dose antipsychotics - aripiprazole / haloperidol First-generation antipsychotic agents (e.g., haloperidol, perphenazine) are associated with hyperprolactinaemia and early (akathisia and parkinsonism) and late (tardive dyskinesia) movement abnormalities, as well as the neuroleptic malignant syndrome. Second-generation antipsychotics (e.g., aripiprazole) are associated with the metabolic syndrome and are not free of the same risks as first-generation antipsychotics: acute and tardive movement disorders and neuroleptic malignant syndrome. Consider antidepressants - sertaline/fluoxetine CLUSTER B (Dramatic) Borderline Same communication style (caution re-nonadherence/loss of trust) Psychotherapy Mood stabilisers, such as lithium and anticonvulsants (lamotrigine), may have some effectiveness in treating impulsivity and aggression in borderline personality disorder. Narcissistic Substance abuse Rx referral Antisocial Psychotherapy ``` CLUSTER C - ANXIOUS Avoidant Psychotherapy 1st - Fluoxetine / sertraline 2nd - gabapentin / pregabalin ``` Dependent Psychotherapy Obsessive compulsive Psychotherapy

Answer 270

Self harm Suicide Impairment in social functioning -

Answer 271

For example, in one study of 290 inpatients with borderline personality disorder, 88% achieved remission; factors were identified to predict an earlier time to remission, including the absence of childhood sexual abuse. Some have suggested symptoms may attenuate with age. Symptoms are often exacerbated in response to stressors. Personality disorders have been shown to respond to treatment, particularly if relatively intensive treatment is provided over an extended time-frame. The 10-year course of borderline personality disorder is also characterised by severe and persistent impairment in social functioning.

Answer 272

``` Grandiose sense of self importance Preoccupation with fantasies of unlimited success, power, or beauty Sense of entitlement Taking advantage of others to achieve own needs Lack of empathy Excessive need for admiration Chronic envy Arrogant and haughty attitude ```

Answer 273

Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone Demonstrates perfectionism that hampers with completing tasks Is extremely dedicated to work and efficiency to the elimination of spare time activities Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness

Answer 274

Hypersensitivity and an unforgiving attitude when insulted Unwarranted tendency to questions the loyalty of friends Reluctance to confide in others Preoccupation with conspirational beliefs and hidden meaning Unwarranted tendency to perceive attacks on their character

Answer 275

``` Indifference to praise and criticism Preference for solitary activities Lack of interest in sexual interactions Lack of desire for companionship Emotional coldness Few interests Few friends or confidants other than family ```

Answer 276

``` Ideas of reference (differ from delusions in that some insight is retained) Odd beliefs and magical thinking Unusual perceptual disturbances Paranoid ideation and suspiciousness Odd, eccentric behaviour Lack of close friends other than family members Inappropriate affect Odd speech without being incoherent ```

Answer 277

``` Ideas of reference (differ from delusions in that some insight is retained) Odd beliefs and magical thinking Unusual perceptual disturbances Paranoid ideation and suspiciousness Odd, eccentric behaviour Lack of close friends other than family members Inappropriate affect Odd speech without being incoherent ```

Answer 278

Benzodiazepine (BZD) overdose occurs when excessive amounts of BZD medications are taken. Commonly known as minor tranquilisers or sleeping pills, BZDs are prescribed for sedative, anxiolytic, hypnotic, and anticonvulsant purposes. BZDs are also widely abused. Acute overdose is characterised by excessive sedation with impaired mental status and diminished postural stability and reflexes. Although BZDs are relatively safe medications, acute overdose may induce respiratory depression resulting in coma and uncommonly death. Diagnosis is suggested by the history and by exclusion of other aetiologies. Chronic overuse increases the risk of many other pathologies. Benzodiazepines (BZDs) are the most commonly prescribed medications for anxiety, sedation, and sleep. Overdose can be intentional in suicidal patients, accidental in combination with other CNS depressants such as alcohol and opioids and in older people, and occasionally by medication error. Older people, who commonly have diminished drug clearance and polypharmacy, are at especially high risk of overdose. The key feature is excessive sedation with unremarkable vital signs and anterograde amnesia. Larger doses can cause coma and respiratory depression. Treatment of overdose is by symptom management, not by quantitative assay. Acute management consists of maintaining airway, respiration, and haemodynamic support while excluding other diagnoses. Assisted ventilation may be necessary. Death is uncommon. Most deaths from BZD overdose are from respiratory depression as a result of mixed overdoses with BZD and other respiratory depressants, particularly alcohol and opioids. The BZD antagonist flumazenil can be used in first-time or infrequent BZD users to reverse CNS depression. It is contraindicated in BZD-dependent patients because of the risk of provoking seizures. The risks associated with its use often outweigh the benefits.

Answer 279

Since initial development in the 1950s, benzodiazepines (BZDs) have become popular in the treatment of various medical disorders and as a drug of abuse. BZDs are the most common hypnotic or sedative medications, other than alcohol, used for recreation. his figure is as high as 36% for adults receiving treatment for depression in mental healthcare settings. BZD use is higher in white people than in other ethnic groups. Twice as many females as males use BZDs. Sedatives, anxiolytics, and hypnotics are commonly prescribed for people in the sixth and seventh decades of life. Non-medical use of BZDs is highest in people aged 18 to 25 years, with rates of 0.7% to 1.9%. Use is especially common in those who abuse alcohol, with up to 40% reporting inter-current or concurrent self-medication with BZDs. BZDs account for approximately 31% of fatal overdoses involving prescription drugs in the US, while 75% of these fatal overdoses also involve opioids.

Answer 280

Benzodiazepines are the most commonly prescribed medications for anxiety, sedation, and sleep. Overdose can be intentional in suicidal patients; accidental in combination with other CNS depressants such as alcohol and opioids, and in older people; and occasionally by medication error (patient administered or iatrogenic). BZDs enhance the activity of the inhibitory neurotransmitter gamma-aminobenzoic acid (GABA) in the CNS. GABA receptors are located on postsynaptic neurons. The binding of a BZD molecule to a site on the GABA receptor complex potentiates the inhibitory effect of GABA. The clinical effects depend on the location of GABA neurons in the CNS and include sleep induction, excitement inhibition, anxiolysis, other sedative/hypnotic and antiseizure action, and generalised CNS depression.

Answer 281

``` STRONG Depression Hx illicit drug use Drug administration error Comorbidity Hx BDZ use Hx polypharmacy Suicidal ideation Older age ``` WEAK Drug interaction Biogenetic susceptibility

Answer 282

COMMON RFs Impaired mental status Drowsiness, slurred speech, ataxia ``` UNCOMMON Coma Respiratory Depression Dec deep tendon reflexes Nystagmus Paradoxical stimulation ```

Answer 283

Supportive - Management of pure benzodiazepine (BZD) overdose is supportive, consisting of airway maintenance, cardiorespiratory monitoring and support, and intravenous fluids. Mixed overdose and other causes of CNS depression should be ruled out. Flumenazil Drug abuse referral - ARC - addiction, recovery, community centre CBT/Motivational therapy

Answer 284

Resp arrest Coma Death

Answer 285

Most patients make a full physical recovery after acute benzodiazepine overdose, but the underlying psychiatric and social issues that precipitated the overdose in many cases need to be addressed in the long term. Patients who have taken an intentional overdose are at risk of future episodes of deliberate self-harm. A greater challenge is treating long-term abuse or dependence. An extensive review of 25 clinical trials, with a total of 1666 subjects, found that cognitive behavioral therapy offers limited benefit, whereas there is insufficient evidence to support motivational therapy or other common approaches in treating abuse or dependence.

Answer 286

``` Pulse Ox FBC Serum chem Serum ethanol Urine toxicology screen ECG Flumazenil ```

Answer 287

Benzodiazepine overdose

Answer 288

Cocaine is a drug of abuse that is usually either insufflated (snorted), injected, or smoked in its freebase form (crack). Cocaine is a type IA antidysrhythmic, local anaesthetic, and sympathomimetic. It can also bind the hERG (slowly depolarising inward potassium channel), which is prodysrhythmic. Episodic cocaine use leads to short-lived states of autonomic arousal. Chronic use can lead to scarring of heart tissue and myocardial hypertrophy and other changes collectively known as myocardial remodelling. These changes constitute the substrate for the occurrence of lethal arrhythmias. Cocaine binds to the hERG (rapid repolarising potassium) channel, disrupting the normal process of depolarisation in heart muscle. Cocaine should not, therefore, be used concomitantly with drugs known to cause QT interval prolongation. While chest pain related to cocaine use is a common reason for seeking medical care, occasional use is rarely associated with acute myocardial infarction (AMI) unless there is pre-existing coronary artery disease. Psychosis can be seen in chronic users as an isolated condition or as a feature of 'excited delirium'. It is an agitated confusional state associated with potentially lethal hyperthermia. There is no evidence to support the use of antipsychotic agents for cocaine dependence. Antipsychotic agents may cause QT interval prolongation and, when used concomitantly with cocaine, may compound the risk of sudden death. OVERDOSE: Occurs within minutes to hours of excessive cocaine use. Some patients may die suddenly before treatment is given. Presentation includes tachycardia, hypertension, hyperthermia, diaphoresis, mydriasis, and agitation. Urine cocaine screen confirms recent cocaine use, but treatment should not be delayed pending results of the test. Treatment may involve supportive care and benzodiazepines; hyperthermia requires rapid cooling to prevent death. Complications such as dysrhythmias, acute coronary syndrome, and intracranial haemorrhage can occur.

Answer 289

It is also known that dopamine-rich neurons in the shell of the nucleus accumbens are deeply involved in the process of addiction to all drugs, and that numerous polymorphisms can alter dopamine metabolism. Genome-wide linkage and association studies have implicated several regions and genes in addiction to alcohol and, more recently, tobacco, but progress in this area has been slower than expected.

Answer 290

Cocaine is the most commonly used illegal stimulant in Europe, and its use is most common in southern and western countries. It is estimated that around 17.5 million European adults aged 15 to 64 years (5.2% of this age group) have used cocaine at some time in their lives. Of these, there are about 2.3 million young adults aged 15 to 34 years (1.9% of this age group) who have used cocaine in the past year.

Answer 291

Hx alcohol drug abuse | Hx mental illness

Answer 292

``` COMMON HTN Tachycardia Chest pain Mydriasis Diaphoresis Tremulousness Agitation Mood changes Anxiety Drug induced formication Hx hospitalisation Body packing Sx Nasal septum ulceration/perforation Seizure LOC Skin lesions Dyspnoea ```

Answer 293

``` Urine Tox - Also do mass spec for Levamisole. Levamisole is now almost a universal cocaine adulterant. ECG CT head EEG Glucose ```

Answer 294

Anxiolytic - BDZ lorazepam, clonazepam, diazepam Tachycardia and hypertension often respond to treatment with sedatives such as benzodiazepines. Lorazepam and alprazolam have shorter durations of action. In patients with mild anxiety, lorazepam or diazepam is preferred. Intravenous use of diazepam requires close monitoring of vital signs. Glyceryl trinitrate, aspirin administration, and cardiac work-up (ECG and cardiac enzymes) are indicated for significant/persistent chest pain. Drug counselling/mental health referral ARC - addiction, rehabilitation and community

Answer 295

``` Cocaine overdose Excited delirium Psychosis (magnum syndrome) Crack keratitis Hypertensive crisis Haemorrhagic stroke Seizures Crack lung HepB/C/HIV MI Cardiomyopathy Chronic skin ulcers Ventricular arrythmias -> sudden cardiac death ```

Answer 296

Cocaine abuse

Answer 297

Cocaine abuse

Answer 298

Detoxification and rehabilitation Abrupt withdrawal from stimulants does not require detoxification and many patients can be safely discharged from the emergency department with referral to a drug-counselling centre. The odds of relapse to drug use are high (about 50%). Patients can benefit from treatment, even those with severe problems related to use. Treatment programme participation of over 90 days has been shown to lead to greater improvement for all patient groups. Occasional user People who have only experimented with the drug rarely require further medical treatment. Education about the dangers of cocaine use, and the offer of resources, may be of benefit. Injection and skin-popping (subcutaneous injection) Intravenous abusers are potentially subject to organ damage and to hepatitis B, hepatitis C, and HIV infection, and will require thorough medical examination before addiction treatment entry.

Answer 299

Cocaine abuse

Answer 300

An opioid is any synthetic or natural agent that stimulates opioid receptors and produces opium-like effects. Opiates are opioids naturally derived from the opium poppy, Papaver somniferum , and include morphine and codeine. Opioids are used in the treatment of pain but are often sold illicitly and abused for their euphoric effects. An overdose occurs when larger quantities than physically tolerated are taken, resulting in central nervous system and respiratory depression, miosis, and apnoea, which can be fatal if not treated rapidly. OD: The patient's history from bystanders/friends/family can assist diagnosis. Signs include central nervous system and respiratory depression, miosis, and apnoea. Initial treatment consists of ensuring adequate ventilation followed by administration of the opioid antagonist naloxone. Monitor patients for re-sedation and repeat antidote dose if necessary.

Answer 301

Opioids are powerful pain killers that are highly addictive. Opioid dependence affects nearly 5 million people in the United States and leads to approximately 17,000 deaths annually. Half of deaths due to drug overdose are related to prescription drugs, according to a report on the leading cause of deaths from injury in the United States.

Answer 302

Opioid overdose can result from the following: Complications of substance abuse in regular users/abusers of illicit or prescription opioids Unintentional overdose in patients prescribed opioids for pain by taking larger amounts than tolerated Intentional overdose and intent of self-harm (suicidality) Therapeutic drug error; iatrogenic overdose by a practitioner unfamiliar with opioid prescribing, or an adverse drug reaction.

Answer 303

STRONG Chronic pain / prescription Recent abstinence in chronic user Hx abuse/dependence

Answer 304

Symptoms of opioid abuse can be categorized by physical state. Intoxication state Patients with opioid use disorders frequently relapse and present with intoxication. Symptoms vary according to level of intoxication. For mild to moderate intoxication, individuals may present with drowsiness, pupillary constriction, and slurred speech. For severe overdose, patients may experience respiratory depression, stupor, and coma. A severe overdose may be fatal. Withdrawal state Symptoms of withdrawal include the following: Autonomic symptoms - diarrhea, rhinorrhea, diaphoresis, lacrimation, shivering, nausea, emesis, piloerection Central nervous system arousal - sleeplessness, restlessness, tremors Pain - abdominal cramping, bone pains, and diffuse muscle aching Craving - for the medication DSMV (at least 2 of): Taking larger amounts of opioids or taking opioids over a longer period than was intended Experiencing a persistent desire for the opioid or engaging in unsuccessful efforts to cut down or control opioid use. Spending a great deal of time in activities necessary to obtain, use, or recover from the effects of the opioid. Craving, or a strong desire or urge to use opioids. Using opioids in a fashion that results in a failure to fulfill major role obligations at work, school, or home. Continuing to use opioids despite experiencing persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids. Giving up or reducing important social, occupational, or recreational activities because of opioid use. Continuing to use opioids in situations in which it is physically hazardous. Continuing to use opioids despite knowledge of having persistent or recurrent physical or psychological problems that are likely to have been caused or exacerbated by the substance. Tolerance, as defined by either a need for markedly increased amounts of opioids to achieve intoxications or desired effect, or a markedly diminished effect with continued use of the same amount of an opioid. Withdrawal, as manifested by either the characteristic opioid withdrawal syndrome, or taking opioids to relieve or avoid withdrawal symptoms.

Answer 305

DSMV (at least 2 of): Taking larger amounts of opioids or taking opioids over a longer period than was intended Experiencing a persistent desire for the opioid or engaging in unsuccessful efforts to cut down or control opioid use. Spending a great deal of time in activities necessary to obtain, use, or recover from the effects of the opioid. Craving, or a strong desire or urge to use opioids. Using opioids in a fashion that results in a failure to fulfill major role obligations at work, school, or home. Continuing to use opioids despite experiencing persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids. Giving up or reducing important social, occupational, or recreational activities because of opioid use. Continuing to use opioids in situations in which it is physically hazardous. Continuing to use opioids despite knowledge of having persistent or recurrent physical or psychological problems that are likely to have been caused or exacerbated by the substance. Tolerance, as defined by either a need for markedly increased amounts of opioids to achieve intoxications or desired effect, or a markedly diminished effect with continued use of the same amount of an opioid. Withdrawal, as manifested by either the characteristic opioid withdrawal syndrome, or taking opioids to relieve or avoid withdrawal symptoms.

Answer 306

Medical: Opioid substitution with methadone or buprenorphine, followed by a gradual taper abrupt opioid discontinuation with the use of clonidine to suppress withdrawal symptoms clonidine-naltrexone detoxification Psychological: Behavioral therapies (e.g., community reinforcement, contingency management) cognitive-behavioral therapies (CBTs) (e.g., relapse prevention, social skills training) psychodynamic therapy/interpersonal therapy (IPT) group and family therapies

Answer 307

The progression from illicitly using opioids to opioid dependence has dire consequences, including a yearly mortality rate of approximately 2%. Moreover, sustained remission from opioid dependence is difficult to achieve.

Answer 308

Dissociative disorders (DD) are conditions that involve disruptions or breakdowns of memory, awareness, identity, or perception. People with dissociative disorders use dissociation as a defense mechanism, pathologically and involuntarily. Some dissociative disorders are triggered by psychological trauma, but dissociative disorders such as depersonalization/derealization disorder may be preceded only by stress, psychoactive substances, or no identifiable trigger at all. Dissociative identity disorder (formerly multiple personality disorder): the alternation of two or more distinct personality states with impaired recall among personality states. In extreme cases, the host personality is unaware of the other, alternating personalities; however, the alternate personalities can be aware of all the existing personalities. Dissociative amnesia: the temporary loss of recall memory, specifically episodic memory, due to a traumatic or stressful event. It is considered the most common dissociative disorder amongst those documented. This disorder can occur abruptly or gradually and may last minutes to years depending on the severity of the trauma and the patient. Dissociative fugue is now subsumed under the dissociative amnesia category. It is described as reversible amnesia for personal identity, usually involving unplanned travel or wandering, sometimes accompanied by the establishment of a new identity. This state is typically associated with stressful life circumstances and can be short or lengthy. Depersonalization disorder: periods of detachment from self or surrounding which may be experienced as "unreal" (lacking in control of or "outside" self) while retaining awareness that this is only a feeling and not a reality. Dissociative seizures also known as psychogenic non-epileptic seizures: seizures that are often mistaken for epilepsy but are not caused by electrical pulses in the brain and are in fact another form of dissociation.

Answer 309

Emerge in adulthood Rare after 50Y The lifetime prevalence of dissociative disorders varies from 10% in the general population to 46% in psychiatric inpatients.

Answer 310

Usually related to stress, ongoing childhood trauma, mechanism of coping with trauma

Answer 311

Stressful life event Way to cope with trauma Childhood abuse/trauma

Answer 312

Dissociative identity disorder (formerly multiple personality disorder): the alternation of two or more distinct personality states with impaired recall among personality states. In extreme cases, the host personality is unaware of the other, alternating personalities; however, the alternate personalities can be aware of all the existing personalities. Dissociative amnesia: the temporary loss of recall memory, specifically episodic memory, due to a traumatic or stressful event. It is considered the most common dissociative disorder amongst those documented. This disorder can occur abruptly or gradually and may last minutes to years depending on the severity of the trauma and the patient. Dissociative fugue is now subsumed under the dissociative amnesia category. It is described as reversible amnesia for personal identity, usually involving unplanned travel or wandering, sometimes accompanied by the establishment of a new identity. This state is typically associated with stressful life circumstances and can be short or lengthy. Depersonalization disorder: periods of detachment from self or surrounding which may be experienced as "unreal" (lacking in control of or "outside" self) while retaining awareness that this is only a feeling and not a reality. Dissociative seizures also known as psychogenic non-epileptic seizures: seizures that are often mistaken for epilepsy but are not caused by electrical pulses in the brain and are in fact another form of dissociation.

Answer 313

Structured clinical interview for DSM-V (SCID-D) | Dissociative experiences scale (DES)

Answer 314

Dissociative identity disorder (multiple personality disorder): Long-term psychotherapy that helps the patient merge his/her multiple personalities into one personality Dissociative amnesia: Psychotherapy, hypnosis, art therapy, cognitive therapy, MED: antidepressants/anti anxiety Dissociative Fugue: hypnosis often used to helped patient recall true identity, psychotherapy Depersonalization disorder: Psychotherapy, hypnosis, art therapy, cognitive therapy, MED: antidepressants/anti anxiety

Answer 315

Dissociative identity disorder (multiple personality disorder) - many years, can relapse, less of a problem after midlife Dissociative amnesia / depersonalisation disorder - as brief as a few seconds or continue for several years. Dissociative fugue - many people recover quickly. The problem may never happen again

Answer 316

Delusional disorder is a generally rare mental illness in which the patient presents delusions, but with no accompanying prominent hallucinations, thought disorder, mood disorder, or significant flattening of affect. Delusions are a specific symptom of psychosis. Delusions can be "bizarre" or "non-bizarre" in content; non-bizarre delusions are fixed false beliefs that involve situations that occur in real life, such as being harmed or poisoned. Apart from their delusions, people with delusional disorder may continue to socialize and function in a normal manner and their behavior does not necessarily generally seem odd. However, the preoccupation with delusional ideas can be disruptive to their overall lives. For the diagnosis to be made, auditory and visual hallucinations cannot be prominent, though olfactory or tactile hallucinations related to the content of the delusion may be present. The Diagnostic and Statistical Manual of Mental Disorders (DSM) defines six subtypes of the disorder characterized as erotomanic (believes that someone is in love with them), grandiose (believes that they are the greatest, strongest, fastest, richest, or most intelligent person ever), jealous (believes that the love partner is cheating on them), persecutory (delusions that the person or someone to whom the person is close is being malevolently treated in some way), somatic (believes that they have a disease or medical condition), and mixed, i.e., having features of more than one subtype.

Answer 317

``` 24-30/100k 1-2% of psychiatric admissions Mid-late adulthood W>M Increased in migrants ```

Answer 318

Erotomanic type (erotomania): delusion that another person, often a prominent figure, is in love with the individual. The individual may breach the law as he/she tries to obsessively make contact with the desired person. Grandiose type (megalomania): delusion of inflated worth, power, knowledge, identity or believes themself to be a famous person, claiming the actual person is an impostor or an impersonator. Jealous type: delusion that the individual's sexual partner is unfaithful when it is untrue. The patient may follow the partner, check text messages, emails, phone calls etc. in an attempt to find "evidence" of the infidelity. Persecutory type: This delusion is a common subtype. It includes the belief that the person (or someone to whom the person is close) is being malevolently treated in some way. The patient may believe that he/she has been drugged, spied upon, harmed, harassed and so on and may seek "justice" by making reports, taking action or even acting violently. Somatic type: delusions that the person has some physical defect or general medical condition Mixed type: delusions with characteristics of more than one of the above types but with no one theme predominating. Unspecified type: delusions that cannot be clearly determined or characterized in any of the categories in the specific types

Answer 319

``` FHx Drug abyse Stress Being married Low Socio Celibacy among men Widowhood among women ```

Answer 320

The following can indicate a delusion: The patient expresses an idea or belief with unusual persistence or force, even when evidence suggests the contradictory. That idea appears to have an undue influence on the patient's life, and the way of life is often altered to an inexplicable extent. Despite their profound conviction, there is often a quality of secretiveness or suspicion when the patient is questioned about it. The individual tends to be humorless and oversensitive, especially about the belief. There is a quality of centrality: no matter how unlikely it is that these strange things are happening to them, the patient accepts them relatively unquestioningly. An attempt to contradict the belief is likely to arouse an inappropriately strong emotional reaction, often with irritability and hostility. They will not accept any other opinions. The belief is, at the least, unlikely, and out of keeping with the patient's social, cultural, and religious background. The patient is emotionally over-invested in the idea and it overwhelms other elements of their psyche. The delusion, if acted out, often leads to behaviors which are abnormal and/or out of character, although perhaps understandable in light of the delusional beliefs. Individuals who know the patient observe that the belief and behavior are uncharacteristic and alien. Additional features of delusional disorder include the following: It is a primary disorder. It is a stable disorder characterized by the presence of delusions to which the patient clings with extraordinary tenacity. The illness is chronic and frequently lifelong. The delusions are logically constructed and internally consistent. The delusions do not interfere with general logical reasoning (although within the delusional system the logic is perverted) and there is usually no general disturbance of behavior. If disturbed behavior does occur, it is directly related to the delusional beliefs. The individual experiences a heightened sense of self-reference. Events which, to others, are nonsignificant are of enormous significance to him or her, and the atmosphere surrounding the delusions is highly charged.

Answer 321

Differential diagnosis includes ruling out other causes such as drug-induced conditions, dementia, infections, metabolic disorders, and endocrine disorders. Other psychiatric disorders must then be ruled out. In delusional disorder, mood symptoms tend to be brief or absent, and unlike schizophrenia, delusions are non-bizarre and hallucinations are minimal or absent. MSE

Answer 322

Most patients Rx as outpatients Individual psychotherapy No real data for antipsychotic use - good if agitated though

Answer 323

Alzheimer's disease (AD) is a chronic neurodegenerative disease with an insidious onset and progressive but slow decline. AD is the most common type of dementia. It often co-exists with other forms such as vascular (mixed-type dementia). The histopathology of AD is characterised by senile plaques, neurofibrillary tangles, and neuronal loss. The hallmark symptoms are memory loss, impairment of daily activities, and neurobehavioural abnormalities. Definition of severity varies according to country, but a commonly accepted categorisation is mild, moderate, and severe. The Mini-Mental State Examination can be used as a guide to cognitive impairment, but education and language must be taken into consideration when interpreting scores. Chronic, progressive neurodegenerative disorder characterised by a global, non-reversible impairment in cerebral functioning. Characterised by memory loss, loss of social and occupational functioning, diminished executive function, speech and motor deficits, personality change, plus behavioural and psychological disturbance. Deteriorating course over up to 8-10 years. Brain lesions are marked by neurofibrillary tangles, senile plaques, neuronal loss and brain atrophy, with defects in acetylcholine synthesis at the cellular level. Treatment requires a multidisciplinary approach with increasing emphasis on behavioural and psychological symptoms. Psychosocial interventions and carer support are key to managing disease course. Caregiver support groups are beneficial to caregivers and should be considered, where available.

Answer 324

5.4% >65yo 30% >90 AD is estimated to account for between 35% and 50% of dementia in older people, depending on geographical, cultural, and racial factors. WM B>W Early onset AD (age <60 years) is often autosomally dominantly inherited and accounts for <1% of cases. AD is the most common type of dementia worldwide.

Answer 325

There are several theories behind the formation of senile plaques and neurofibrillary tangles. The amyloid hypothesis is currently the most commonly accepted explanation. Brains from Alzheimer's patients have an excess of interneuronal amyloid (Abeta) peptides, due to overproduction or diminished clearance of beta-amyloid. This leads to the formation of dense amyloid oligomers, which are deposited as diffuse plaques. These plaques cause an inflammatory process through microglial activation, cytokine formation, and activation of the complement cascade. Inflammation leads to the formation of neuritic plaques, causing synaptic and neuritic injury and cell death. Lifestyle factors including smoking, midlife obesity, and a diet high in saturated fats have also been correlated with an increased risk for the development of AD.

Answer 326

``` STRONG Increased age Fix Genetics (Presenilin 1 + APP) Down's syndrome Cerebrovascular disease Hyperlipidaemia Lifestyle (smoking, obesity, high satfat) Less than secondary school education ``` ``` WEAK Low IQ Traumatic brain injury Depression DM Female sex Elevated plasma homocysteine level Artificial sweetened soft drink consumption ```

Answer 327

``` COMMON RFs Memory loss Disorientation Nominal dysphasia Misplacing items/getting lost Apathy Decline in activities of daily living Personality change Normal initial physical examination ``` OTHER COMMON Mood changes Poor abstract thinking Constructional dyspraxia - Parietal lobe deficits may lead to difficulties completing the clock-drawing test or intersecting pentagons in the Mini-Mental State Examination. UNCOMMON Prosopagnosia

Answer 328

Minimental state examination MMSE - impaired recall, nominal dysphasia, disorientation (to time, place, and eventually person), constructional dyspraxia, and impaired executive functioning 24/30 = N Below this, scores can indicate severe (≤9 points), moderate (10–18 points) or mild (19–23 points) cognitive impairment. The raw score may also need to be corrected for educational attainment and age. FBC - Rule out anaemia U+E - rule out abnormal TSH - Rule out hyperthyroid- or hypothyroid-associated dementia. B12 - rule out B12 deficiency-induced dementia Urine drug screen CT - may exclude space-occupying lesions or other pathology MRI - generalised atrophy with medial temporal lobe and later parietal predominance

Answer 329

1. Supportive treatment - OT input - home safety evaluation - Prepare power of attorney for healthcare 2. Environmental control - Measures such as identification bracelets or installing sound and motion detectors make the environment safe for wandering patients and minimise the burden on carers. ``` MEDICAL CHOLINESTERASE INHIBITORS Donepezil max 23mg oral Rivastigmine max 12mg oral Galatamine max 24mg oral day ``` SEVERE DISEASE ADD OR CHANGE TO MEMANTINE COTREAT DEPRESSION - MAY HELP SX Sertaline 50-100mg orally OD Citalopram 10-40mg OD Mirtazapine: 15-45 mg orally once daily ANTIPSYCHOTIC USE Antipsychotic use in patients with Alzheimer's disease is increasingly controversial. Many clinicians continue to use these medications for symptoms such as agitation, wandering, hallucinations, and delusions. If there is any evidence of vascular dementia their use should be avoided. INSOMNIA MANAGEMENT Trazodone: 25-50 mg orally once daily at bedtime, maximum 200mg/day AGGRESSION MANAGEMENT Aggression has multiple causes in Alzheimer's disease (AD). These include acute confusion, paranoid delusions, agitation or irritability stemming from comorbid depression, or adverse effects of medication. Citalopram 10mg max 30 Lorazepam 0.5mg orally/OM

Answer 330

``` Pneumonia Insitutionalisation UTI Falls + complications Elder abuse Weight-loss ```

Answer 331

The natural course is of progressive decline with some plateaus. Some data exist showing that current medications slow the rate of progression or temporarily improve cognition, but overall the current treatment options do not provide solid evidence of improving cognitive function. Cholinesterase inhibitors and NMDA receptor antagonists should be discontinued if there are intolerable adverse effects or there is poor compliance because of financial or other social issues. Family education and referral to resources such as the Alzheimer's Association are vital, as patient care requires coordination between physician, carer, family, friends, social worker, psychologist, and community supports.

Answer 332

Alzheimer's dementia

Answer 333

Alzheimer's dementia

Answer 334

Essential for a diagnosis of dementia with Lewy bodies (DLB) is dementia, defined as a progressive cognitive decline of sufficient magnitude to interfere with normal social or occupational functions, or with usual daily activities. DLB is characterised by the following core clinical features (the first 3 typically occur early, and may persist throughout the course): fluctuating cognition; recurrent visual hallucinations; REM sleep behaviour disorder; and one or more spontaneous cardinal symptoms of parkinsonism: bradykinesia, rest tremor, or rigidity. Prominent or persistent memory impairment may not necessarily occur in the early stages but is usually evident with progression. Deficits on tests of attention, executive function, and visuoperceptual ability may be especially prominent and occur early. Disease course is progressive, although treatment may help some cognitive, sleep, motor, and behavioural symptoms. DLB should be distinguished from neurocognitive disorder associated with Parkinson's disease, although there are areas of clinical overlap. A neurodegenerative disorder with parkinsonism, progressive cognitive decline, prominent executive dysfunction, and visuospatial impairment. Core clinical features include: recurrent visual hallucinations; cognitive fluctuations; REM sleep behaviour disorder; and one or more spontaeous cardinal features of parkinsonism: bradykinesia, rest tremor, or rigidity. Supportive clinical features include sensitivity to antipsychotic agents, postural instability and falls, syncope, autonomic dysfunction, delusions and non-visual hallucinations, apathy, anxiety, and depression. Diagnosis is made clinically and can only be confirmed pathologically by the presence of Lewy bodies. Many patients have concomitant Alzheimer's disease (AD)-type pathology. Meta-analyses support the use of cholinesterase inhibitors for the cognitive and the neurobehavioural symptoms. Memantine may be of some value in the treatment of dementia and behavioural symptoms. The use of antipsychotic medication must be minimised due to the increased sensitivity to these medicines' adverse effects, including increased mortality. Levodopa/carbidopa can be used for the motor symptoms, though adverse effects may be restrictive and response limited; clonazepam is effective for REM sleep behavioural disorder.

Answer 335

10% of all dementia cases | Incidence 0.1%/yr

Answer 336

The aetiology of DLB is not known. Possible causative mechanisms include: Toxic protein aggregation Abnormal phosphorylation Other molecular mechanisms such as nitration, inflammation, oxidative stress, and lysosomal dysfunction. Almost all DLB cases are sporadic However, familial clusters have been reported. It is likely that genetic factors contribute to DLB pathogenesis. Most are autosomally dominantly inherited, though autosomal recessive inheritance has also been implicated. Genes identified in families with DLB include the alpha-synuclein gene on chromosome 4, and apolipoprotein E e4 allele. Other genes implicated include SNCA and glucocerebrosidase (GBA). There does not appear to be an association with MAPT locus, unlike that found in Parkinson's disease.

Answer 337

STRONG Older age WEAK Male Fix

Answer 338

COMMON RFs Cognitive fluctuations/arousal/attention Visual hallucinations - well formed + visual Motor symptoms - Spontaneous parkinsonian features, not due to antidopaminergic medications or stroke, are present in over 85% of patients with DLB. Parkinsonism in Parkinson's disease is defined as bradykinesia in combination with rest tremor, rigidity, or both. REM sleep behavioural disturbance - vivid dreams are accompanied by loss of associated atonia of REM sleep. Patients tend to act out their dreams. Vocalisation, as well as violent and unpredictable movements, may occur. OTHER COMMON Antipsychotics worsen motor symptoms and consciousness DO NOT USE. Depression Repeated falls and syncope (autonomic dysfunction) Orthostatic hypotension (autonomic dysfunction) Urinary incontinence (autonomic dysfunction) Constipation (autonomic dysfunction) Attention + visuospatial abnormalities Delusions Hypersomnia Hyposomnia UNCOMMON Auditory hallucinations

Answer 339

``` FBC - rule out (RO) anaemia Met panel - rule out derangements TSH - rule out (RO) hyper- or hypothyroid-associated dementia. B12 - RO b12 ass. Folate - RO deficiency VDRL - RO syphilis dementia Urine drug - RO rec drug use Urinalysis - RO UTI HIV test - rule out HIV (at risk with dementia) ```

Answer 340

ACUTE + Agitated BDZ: Lorazepam 0.5mg orally/IM Oxazepam 10-15mg orally QDS ``` ONGOING Cholinesterase inhibitors: Donepezil Rivastigmine Galantamine ``` IF VERY PSYCHOTIC Atypical anti-psychotics Risperidone/olanzapine/quetiapine (typical antipsychotics worsen Parkinsonism => CONTRAINDICATED) COMORBID DEPRESSION Sertraline 50mg orally OD Citalopram 10mg orally OD WITH REM DISORDER Melatonin Clonazepam SEVERE PARKINSONISM: Dopaminergic agents, typically levodopa, should be given in small doses and titrated slowly. Few controlled trials are available, and caution should be exercised due to possible worsening of cognition, hallucinations, and behaviour; may worsen cognitive and/or behavioural deficits; lowest possible dose should be used and only if necessary. Because of these potential adverse effects, motor symptoms should be treated only if they are severe and interfere with activities of daily living. A significant motor response is seen in approximately one third of patients, with younger patients responding better. Non-pharmacological approaches to psychosis include providing a comfortable environment with adequate lighting, correcting vision, and decreasing visual triggers. Increasing social engagement and ongoing activities may help mask psychotic symptoms.

Answer 341

``` Pneumonia Institutionalisation Dysphagia Antipsychotic sensitivity Urinary incontinence and catheterisation complications Falls Elder abuse ```

Answer 342

Treatment is symptomatic and is unlikely to entirely prevent cognitive and behavioural disturbance. The course of disease is progressive, and a steady decline in functioning leads to eventual institutionalisation, loss of independence, and death. A retrospective study of DLB cases confirmed by autopsy showed an average survival of about 5 years. A further study demonstrated a survival time of around 7 years after symptom onset, with higher mortality than with Alzheimer's disease.

Answer 343

dementia with Lewy bodies

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dementia with Lewy bodies

Answer 345

Frontotemporal dementias (FTDs) are the second most frequent primary neurodegenerative brain diseases (after Alzheimer’s disease) in adults <65 years of age. The FTD spectrum comprises a heterogeneous group of conditions that appear heritable in some cases. Prominent early symptoms include progressive coarsening of personality, social behaviour, self-regulation (of emotions, drives, and behaviour), and language. FTDs typically appear in mid-life, with peak onset in the sixth decade. Gross changes in social behaviour and language are often seen, including indifference to self-care and others' needs, loss of speech and comprehension, loss of empathy, distractibility, impulsiveness, disinhibition, stereotyped behaviours and rigid routines, and compulsions. Manifests primarily as disruption in personality and social conduct, or as a primary language disorder. Almost 50% of all affected people display parkinsonism; a smaller subset may have motor neuron disease. Clinical diagnosis derives primarily from examination and brain imaging. Diagnostic confirmation is based on pathological examination or identification of gene mutation. Treatment is supportive, combining medications with carer guidance, community services, and social work interventions.

Answer 346

15 cases per 100,000 in adults aged 45 to 64 years M>F When the therapeutic aim is to slow the progress of dementia, the lack of reliable criteria to distinguish early FTD from other pre-dementia syndromes remains a major obstacle in the design of clinical trials. The Zuid-Holland epidemiological study reported a positive family history in 43% of cases

Answer 347

The Zuid-Holland epidemiological study reported a positive family history in 43% of cases Genes found: MAPT chr 17 PGRN chr 17 Known mutations (in MAPT and PGRN genes) could account for <20% of cases.

Answer 348

COMMON Disregard for social conventions, slovenly appearance, impatience and irritability, argumentativeness, lewd and tactless remarks, child-like and impulsive actions, loss of empathy and concern for others, compulsions, and rigid adherence to routines. In FTD, changes in personality, language, habits, and activity generally precede the development of memory impairment, disorientation, or apraxias. Development of memory impairment, disorientation, or apraxias OTHER COMMON Age at onset peak in mid-50s Fix Altered eating habits - (fads, gorging, and gluttony) Inattentiveness, puerile preoccupations, economy of effort, and impulsive responding UNCOMMON Sx of Amytrophic lateral sclerosis - progressive asymmetrical weakness of spinal or bulbar muscles and muscle wasting. Parkinsonian Sx Fasciculations, atrophy, hyper-reflexia, and other signs of motor neuron disease Glabellar, snout, sucking, rooting, or grasp reflex Loss of bladder/bowel control

Answer 349

MMSE - < score <24= impairment - disproportionately poor performance in test-taking behaviour and/or in tests of executive functioning; poor emotional processing MOCA (montreal cognitive assessment) - disproportionately poor performance in test-taking behaviour and/or in tests of executive functioning; poor emotional processing Brain MRI/CT - focal atrophy in the frontal and/or anterior temporal lobes; frequently the atrophy is characterised by left-right asymmetry ``` RULE OUT: FBC - anaemia ESR/CRP - inflammatory conditions TSH/T4 - hypothyroidism Met panel Urea+creatinine - renal failure B12/folate Syphilis HIV testing ELISA for B.burgdorferi - rule out lyme ```

Answer 350

The first step in the care of a patient with FTD is to educate the patient and carer about the illness, focusing on its key features and how these translate to care needs. The discussion also serves as the context for presenting preliminary plans for managing present-day needs and any behavioural complications and for tailoring these to the patient's needs. It is also important to address long-term care needs early, because early planning and action maximise options and the patient's ability to participate. The clinical team should initiate processes that empower carers to assist the patient in making decisions regarding health and property, managing finances, taking medicines, cooking meals, etc. Aggression/restlessness BDZ - lorazepam Neuroleptic - quetiapine/olanzapine Many patients cannot be managed at home without a professional aide in the home to provide respite to the family, and supervision and assistance to the patient. In many cases, continued home care is no longer possible due to the nature of the care environment (e.g., a spouse who cannot retire) or of the problem behaviours (e.g., night-time roaming, belligerent behaviour). Daycare services can offer respite to weary carers and patients, and may be used in combination with in-home care. Patients who require residential care should generally be cared for in a specialised dementia unit. WITH COMPULSIONS Citalopram, sertraline, fluoextine WITH Hyposomnia Mirtazipine/trazodone/lorazepam WITH Mania valproate semisodium: consult specialist for guidance on dose WITH gluttony Topiramate - 25mg OD

Answer 351

Median survival is 80 months from diagnosis Compared with patients with Alzheimer's disease, FTD patients have shorter survival and faster rates of cognitive and functional decline. Survival appears to be shorter for patients with parkinsonism and those with motor neuron disease,

Answer 352

Financial crisis Dangerous driving Parental relationship breakdown Legal crisis

Answer 353

frontotemporal dementia

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frontotemporal dementia

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frontotemporal dementia

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frontotemporal dementia

Psychiatry Flashcards

(385 cards)