1
Q
What is the DSM-5 criteria for Borderline personality disorder?
A
- *CODE:301.83**
- *5** or more of the following:
- Frantic efforts to avoid real or imagined abandonment (exc. suicidal or self-mutilating behaviour)
- A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of Idealisation and devaluation.
- Identity disturbances: markedly and persistently unstable self-image or sense of self.
- Impulsivity in at least two areas that are potentially self-damaging (eg. spending, sex, substance abuse, reckless driving, binge eating)
- Recurrent suicidal behaviour gestures, or threats, or self-mutilating behaviour.
- Affective instability due to a marked reactivity of mood (eg. intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
- Chronic feelings of emptiness.
- Inappropriate, intense anger or difficulty controlling anger (eg. frequent displays of temper, constant anger, recurrent physical fights)
- Transient, stress related paranoid ideation or severe dissociative symptoms
2
Q
What is this personality disorder?
CODE:301.83
5 or more of the following:
- Frantic efforts to avoid real or imagined abandonment (exc. suicidal or self-mutilating behaviour)
- A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of Idealisation and devaluation.
- Identity disturbances: markedly and persistently unstable self-image or sense of self.
- Impulsivity in at least two areas that are potentially self-damaging (eg. spending, sex, substance abuse, reckless driving, binge eating)
- Recurrent suicidal behaviour gestures, or threats, or self-mutilating behaviour.
- Affective instability due to a marked reactivity of mood (eg. intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
- Chronic feelings of emptiness.
- Inappropriate, intense anger or difficulty controlling anger (eg. frequent displays of temper, constant anger, recurrent physical fights)
- Transient, stress related paranoid ideation or severe dissociative symptoms
A
Borderline personality disorder
3
Q
What is the study that provides significant justification for the treatability of borderline personality disorder
A
Zanarini et al. (2010) conducted a study which followed 300 people diagnosed with BPD for 10 years. They found that over 50% of participants achieved full recovery (no longer fit the diagnostic criteria for BPD) and achieved reasonable social and occupational functioning.
4
Q
What is the typical triggering event for borderline personality disorder?
A
Frantic efforts to avoid real or imagined abandonment
5
Q
What personality disorder is the following triggering event related to? Frantic efforts to avoid real or imagined abandonment
A
Borderline personality disorder
6
Q
What is the interpersonal style characteristic of borderline personality disorder?
A
Paradoxical instability: Quick fluctuation between idealising and clinging to another person, and then devaluing and opposing that person.
They go to great lengths to avoid being alone (inc. indiscriminate sexual affairs, late night phone calls, and visits to hospitals with vague complaints).
7
Q
What personality disorder is this interpersonal style characteristic of? Paradoxical instability. Quick fluctuation between idealising and clinging to another person, and then devaluing and opposing that person. They go to great lengths to avoid being alone (inc. indiscriminate sexual affairs, late night phone calls, and visits to hospitals with vague complaints).
A
Borderline personality disorder
8
Q
What is the cognitive style which is characteristic of borderline personality disorder?
A
- Inflexible and impulsive. Reasoning is based on analogy from past experience and patients have difficulty reasoning logically
9
Q
What personality disorder is this cognitive style characteristic of?
- Inflexible and impulsive. Reasoning is based on analogy from past experience and patients have difficulty reasoning logically
A
Borderline personality disorder
10
Q
What is the locus of control in borderline personality disorder?
A
External
11
Q
What is the affective style which is characteristic of borderline personality disorder?
A
- Marked shifts between euthymic to dysphoric mood. Easy triggering of intense rage Feelings of emptiness or boredom
12
Q
What personality disorder is this affective style characteristic of?
- Marked shifts between euthymic to dysphoric mood. Easy triggering of intense rage Feelings of emptiness or boredom
A
Borderline personality disorder
13
Q
What is the attachment style which is characteristic of borderline personality disorder?
A
- Disorganised attachment style which is associated with dissociative symptomology.
14
Q
What is the primary suggested aetiology for borderline personality disorder?
A
Childhood abuse.
15
Q
What is the prototypic description of borderline personality disorder?
A
These individuals have intense and frustrating relationships which predictably degenerate into conflict. Fear of abandonment leads them to impose unrealistic demands on others. Fragile sense of self Impulsive sexual and aggressive behaviour
16
Q
The following is a prototypic description of which personality disorder?
These individuals have intense and frustrating relationships which predictably degenerate into conflict. Fear of abandonment leads them to impose unrealistic demands on others. Fragile sense of self Impulsive sexual and aggressive behaviour
A
Borderline personality disorder
17
Q
What is the psychodynamic case conceptualisation of borderline personality disorder
A
Stems from Kernberg (1975), Masterson (1976) and Masterson and Klein (1989).
Error in rapprochement sub-phase of separation-individuation theory which prevents development of an internalised image of the mother due to mothers emotional unavailability. Also atypical relationship with mother, with mother not wanting the child to grow up ‘if you grow up something will happen to me’
18
Q
What is the mentalisation approach case definition of borderline personality disorder
A
Bateman and Fonargy (2007).
Problem with mentalising (the process through which individuals interpret their own subjective cognitions, behaviours, and emotions, as well as those of others.) Proposes that this arises due to poor quality object relationships early in life, subsequent to neglect, abuse, or poor parental relationships.
19
Q
What is the biopsychosocial case conceptualisation of of borderline personality disorder?
A
Millon and Davis (1996)
Lack of clear and coherent sense of identity is central to the pathogenesis of BPD. Identity confusion is the result of biopsychosocial factors that combine to impair a coherent sense of identity.
20
Q
What is a description of a borderline-dependent person?
A
Passive infantile pattern of behaviour. Strong attachment and dependency to a single caregiver.
21
Q
What is a description of a borderline-histrionic person?
A
- Hyperresponsiveness to stimulation.
- Feels accepted only where their behaviour is explicitly approved by others.
- ‘Performs’ to secure support and attention.
22
Q
What is a description of a borderline-passive aggressive person?
A
- ‘Difficult child’ temperaments
- Erratic behaviour
- Highly vacillating
- Aggressive and passive aggressive
23
Q
What is the self view of someone with borderline personality disorder?
A
- Identity problems involving gender, career, loyalties, and values.
- Self esteem fluctuates with current emotions
24
Q
What is the world view of someone with borderline personality disorder?
A
Paradoxical and vacillating
25
What are the **maladaptive schemas** associated with borderline personality disorder?
* Fear of **abandonment**
* Emotional deprivation
* Mistrust
* Social isolation
* Self control (Insufficient self control)
26
What are the primary **treatments** for borderline personality disorder?
* **Dialectical behavioural therapy** is the mainstay.
* Medications are usually for control of affective instability, aggression, transient psychotic episodes, and self-harm
* **Affective instability** - Lithium and carbamazepine
* **Aggression** - Serotonergic agents (fluoxetine and sertraline. MAOI only if other treatments unsuccessful)
* **Transient psychosis** - atypical antipsychotics
* **Self-harm** - SSRI (if not succsesful, add naltrexone) Seroquel is prescribed generally for anxiety reduction.
27
What are the three stages of **dialectical behavioural therapy** in borderline personality disorder?
1. Focus on reducing **parasuicidal** and **suicidal** behaviours, **therapy interfering** behaviours, and behaviours that reduce **quality of life**.
2. Focus on difficult problems like **PTSD** and **prior abuse**.
3. Focus on **building self esteem** and individual treatment **goals**.
28
What are the **general** diagnostic criteria for a personality disorder?
1. An **enduring pattern** of i**nner experience and behaviour that deviates markedly from the expectations of the individual's culture**, manifesting in the following areas: Cognition, affectivity, interpersonal functioning, impulse control.
2. The enduring pattern is **inflexible and pervasive** across a broad range of personal and social situations
3. The enduring pattern leads to **clinically significant distress or impairment** in social, occupational, or other important areas of functioning.
4. The pattern is **stable and of long duration**, and its onset can be traced back at least to **adolescence** **or early adulthood**.
5. The enduring pattern is **not better explained** as a manifestation or consequence of another mental disorder
6. The enduring pattern is **not attributable** to the psychological effects of a substance (drugs) or another medical condition (head trauma)
29
What are the **Cluster A** personality disorders?
**Odd / eccentric**:
* Paranoid personality disorder
* Schizoid personality disorder
* Schizotypal personality disorder
30
What are the **Cluster B** personality disorders
**Dramatic / emotional / erratic**:
* Antisocial personality disorder
* Borderline personality disorder
* Histrionic personality disorder
* Narcissistic personality disorder
31
What are the **Cluster C** personality disorders
**Anxious / fearful**:
* Avoidant personality disorder
* Dependent personality disorder
* Obsessive-compulsive personality disorder
32
What are the broad traits of **Cluster A** personality disorders?
* Avoidance
* Rigidity
* Impairment of reality testing
33
What are the broad traits of **Cluster B** personality disorders?
* Antisocial attitudes
* Impulsivity
* Emotional dysregulation
34
What are the broad traits of **Cluster C** personality disorders?
* Avoidance
* Preoccupied anxiety
35
What are the **risk factors** for Anorexia Nervosa?
* **Perfectionism** and poor self-esteem
* Early **menarche**
* Exposure to environment in which **weight concerns and restrictive dieting** prevails
* **Family history** of members who are thin or underweight
36
What is a **general description** of Anorexia Nervosa?
Intense **preoccupation with weight and body shape** and a **relentless pursuit of thinness.**
37
What are the **three key clinical features** of Anorexia Nervosa?
1. **Underweight** for height and age
2. Intense **fear of fatness** and gaining weight, or behaviours to **avoid weight gain**
3. O**vervalued ideas of body weight** and shape on self-view, or denial of seriousness of low weight
38
What are common **behavioural characteristics** of people with Anorexia Nervosa?
* Vomiting and laxative abuse
* Excessive exercise (sometimes covert)
* **Both carried out obsessively with guilt present when not done.**
39
What are the **physical and biochemical findings** associated with Anorexia Nervosa?
* Decresed **gonadotropins** & sex hormones
* Altered **thyroid** metabolism
* Raised **cortisol** and **GH**
* Severe **electrolyte** disturbances (Potassium, calcium, phosphates)
* Cardiac **arrhythmias**
* **Renal** failure
* **Osteopenia** / osteoporosis
* Rectal **prolapse**
40
In the emergency treatment of Anorexia Nervosa what are the 12 categories of changes that must be monitored and treated?
DR, I GET salty CHIPS
* Dental changes
* Renal changes
* Intercellular changes
* Gastrointestinal changes
* **Endocrine changes**
* Temperature changes
* **Electrolyte changes**
* **Cardiac changes**
* **Haematological changes**
* Immune system changes
* Pregnancy changes
* Skin / bone changes
41
What is the main **intercellular change** in Anorexia nervosa and how is it monitored and managed acutely?
Change:
* Increased protein catabolism
Monitoring:
* Measure pulse and BP lying and standing
42
What are the main **Endocrine changes** in Anorexia nervosa and how are they monitored and managed acutely?
Changes:
* Dehydration
* Oedema
* **Low gonadotropin and sex steroids** (amenorrhea)
* Altered **peripheral metabolism of thyroid hormone**
* **Raised cortisol and GH**
* Hyperaldosteronism
* **Hypoglycaemia**
* Poor metabolic control in T1DM (needs specialist referral)
Monitoring:
* **TFT**
* Monitor hormone imbalances
* Repeated **BSL** monitoring
Acute management:
* **Thiamine** administration with refeeding for hypoglycaemia
43
What are the main **Electrolyte changes** in Anorexia nervosa and how are they monitored and managed acutely?
Changes:
* **Hypokalaemia**
* Hypochloraemia
* **Metabolic alkalosis**
* Hypomagnesaemia (\*\*refractory hypokalaemia)
* **Hypoglycaemia**
* Hypophosphatemia
* Hyperphosphataemia (vomiting)
Monitoring:
* **Electrolytes**
* **Blood gas**
* **ECG**
Acute management:
* Careful **K+ replacement** (oral)
* Correct alkalosis
44
What are the main **Gastrointestinal changes** in Anorexia nervosa and how are they monitored and managed acutely?
Changes:
* Acute **pancreatitis**
* Parotid and salivary gland hypertrophy
* Reduced gastric motility
* **Oesophagitis** / ulceration / strictures
* **Mallory-weiss** tears
* Gastric **rupture**
* Diarrhoea
* Raised liver enzymes
* Low albumin
Monitoring:
* **Physical exam (gastro)**
* **LFT (AST &ALP) + Lipase**
Acute management:
* Surgical referral for complications
* Bowel rest,
* **NG suction, and fluid replacement for pancreatitis**
45
What is the main **Haematological change** in Anorexia nervosa and how is it monitored and managed acutely?
Change:
* **Anaemia**
Monitoring:
* **FBE** +/- Iron studies
* B12
* Folate
Management:
* **Oral** replacement therapies
46
What is the main **Body Temperature change** in Anorexia nervosa and how is it monitored and managed acutely?
Change:
* **Hypothermia**
Monitoring:
* Repeated temperature measurement
* Observe for signs of infection as **hypothermia can mask pyrexia**
47
What are the main **Immune function changes** in Anorexia nervosa and how are they monitored and managed acutely?
Change:
* **Low white cell count**
* Susceptibility to **bacterial** infections
Monitor:
* **FBE**
* Monitor for signs of infection
48
What are the main **Cardiovascular changes** in Anorexia nervosa and how are they monitored and managed acutely?
Changes:
* Bradycardia and hypotension
* **Arrhythmias**
* Cardiomyopathy (**Ipecac** (emetic) use)
Monitoring:
* **ECG (always)**
* CXR
Treatment:
* Symptomatic oedema treatment
* **Treatment of arrhythmia**
49
What are the main **Renal changes** in Anorexia nervosa and how are they monitored and managed acutely?
Changes:
* **Elevated UEC** (increased muscle catabolism)
* **Hypokalaemic nephropathy**
* Reduced serum **creatinine** (muscle breakdown)
* High ketones
* **Polyuria**
Monitoring:
* UEC
Treatment:
* If needed, specialist referral
50
What are the main **Skin / Bone changes** in Anorexia nervosa and how are they monitored and managed acutely?
Changes:
* Osteopenia / **stress fractures**
* Brittle hair and **hair loss**
* **Lanugo hair**
* **Vomiting** and signs of vomiting initiation
* Dorsal hand abrasions
* Facial purpura
* Conjunctival haemorrhage
Monitoring:
* Dexa scan
Treatment:
* Calcium and vitamin D supplementation **DO NOT GIVE PHOSPHATE**
51
What is the main **Dental change** in Anorexia nervosa and how is it monitored and managed acutely?
Change:
* Erosions and **perimyolysis**
Monitoring and treatment:
* Dental referral
52
What are the **pregnancy complications** in patients with Anorexia Nervosa?
* Spontaneous abortion
* Perinatal mortality
* **Prematurity**
* **Low birth weight**
* **Congenital malformations**
53
What is the **general exam findings** in a patient with suspected Anorexia Nervosa?
* **Mitral prolapse and irregular pulse**
* Oedema
* Stress fractures
* Acrocyanosis
* **Lanugo hair**
* Enlarged thyroid
* **Low weight**
* Abrasions on the dorsum of the hand
* Dental erosions
* **Perimyolysis**
54
What are some key points to cover when **discussing treatment** with someone with Anorexia Nervosa?
* Resuming normal eating will diminish preoccupation with food, relieve tiredness and depression, and facilitate improved relationships.
* They will not be confined to a bed
* They will not be force fed
* They will not be isolated from friends and family
* They will not become obese
* **Compromise cannot be made on food intake** (you can't be a little anorexic)
55
What is **refeeding syndrome**?
When metabolism is stimulated by refeeding and demand for substances like **potassium and phosphates** increases. Since reserves are depleted this causes a **rapid drop** in serum concentrations.
56
What are the **significant signs** of **refeeding syndrome**?
* SOB
* Oedema
* Weakness
* Seizures
* Delirium
* Coma
57
What is Bulimia Nervosa?
A **cyclic pattern** of behaviour typified by episodes of **binges and uncontrolled overeating, associated with shame**. Can be **restricting** (over exercise) or **purging** (vomiting, emetics, laxatives) types
58
What are the four primary clinical features of Bulimia Nervosa?
1. Recurrent binge eating or uncontrolled overeating
2. Use of **extreme measures** to control weight (purging and non-purging)
3. Overvalued ideas of body weight and shape on self view
4. **Normal weight or overweight**
59
What are the most significant **electrolyte changes** observed in patients with **Bulimia Nervosa**?
* Decreased serum potassium
* Metabolic acidosis
60
What **ECG changes** are associated with **hypokalaemia**?
* Increased amplitude and width of P wave
* Prolonged PR interval
* T wave flattening and inversion
* ST depression
* Prominent U waves (on precordial leads)
* **long QT (really fusion of T and U waves)**
61
Which drugs has been shown to attenuate binge eating independent on its effects on other psychological / psychiatric disturbances?
SSRIs
62
What is Binge eating disorder?
A disorder characterised by recurrent episodes of binge eating **without the need for compensation**
63
What are the 4 key clinical features of **Binge eating disorder**?
1. Recurrent and distressing binge eating
2. **No** regular use of extreme measures to control weight
3. Overvalued ideals of body weight and shape on self-view \***not required**\*
4. Normal weight or overweight
64
What are the **two goals** in treatment for Anorexia Nervosa?
1. The **restoration of normal weight** for height and age
2. Identification and **management of any contributing family and personal problems**
65
What is the indicated **pharmacological treatment** in Anorexia Nervosa?
Drugs are of **no proven benefit** for primary Anorexia Nervosa.
Antidepressants can be prescribed IF the patient has a **persistently depressed mood, neurovegetative symptoms, and depressive ideation**. TCAs and MAOIs should be used only as a last resort and with comprehensive monitoring for cardiotoxicity. Treatment is in line with depression guidelines, but **all dosages are halved**.
\*\*Olanzapine may be used if the patient is extremely agitated
66
What is the **pharmacological treatment** used in **Bulimia Nervosa?**
First line:
* **Fluoxetine** (20-60mg)
Second line:
* Citalopram (10-40mg)
* Fluvoxamine (50-300mg)
* Sertraline (50-200mg)
67
What is the preferred **non-pharmacological treatment** for eating disorders in general?
* **CBT**
* Psychoeducation
* Nutritional advice / planning
68
What is a general description of **post-traumatic stress disorder**?
Long-lasting and debilitating anxiety in **response to an extreme stressor**
69
What is a general description of **acute stress disorder**?
**Short-lasting** debilitating anxiety in response to an **extreme stressor**
70
What are some examples of **extreme stressors** which may give rise to acute stress disorder or PTSD?
* **Serious motor accident**
* Natural disaster
* Significant assault (inc. **childhood abuse**)
* **Active military service**
* Displacement as a **refugee**
* Witnessing or learning about the sudden death of a loved one
71
What is the length of time for **acute stress disorder**?
1 month
72
What is the length of time for **acute post-traumatic stress disorder**
1-3 months
73
What is the length of time for **chronic post traumatic stress disorder?**
\>3 months
74
What is **delayed post-traumatic stress disorder?**
PTSD where the symptom onset is delayed by **6-months or longer** from the initial stress exposure
75
What factors increase the **risk** of developing PTSD?
* **Intensity**, frequency and duration of the traumatic event.
* **Proximity** to the traumatic event
* The **nature** of the trauma (physical injury, interpersonal violence)
* Gender (**female**)
* **Previous exposure** to trauma
* Prior psychiatric illness
* Ability to receive support
76
What is the presentation of PTSD?
* **Re-experiencing** the traumatic event
* **Triggered** by minor stimuli
* **Avoidance** of triggers
* Increased **arousal**
* Emotional **numbing**
* Survivor guilt (war veterans)
* Self-disruptive behaviour (rape survivor)
77
What are some screening questions for PTSD?
* What is the worst thing that has ever happened to you?
* Have you ever experienced or witnessed an event in which you were, or thought you were seriously injured or your life was in danger?
* Do you think or dream about those events?
78
What are the three **cluster symptoms** of PTSD?
* Re-experiencing
* Hyperarousal
* Avoidance and numbing
79
What is the **early intervention** (first few days) after a traumatic experience?
* Practical and emotional support
* Structured interventions and psychological debriefing should **not take place on a routine basis**
* No pharmacotherapy
80
What is the **first line treatment** for acute stress disorder and PTSD?
* Specialist administered **trauma-focussed psychotherapy.**
* No medication for acute stress disorder
* No medication for first **4-8 weeks** of PTSD
81
What are the **trauma focussed psychotherapies** used in acute stress disorder and PTSD?
* **Trauma focussed CBT**
* Eye movement desensitisation and reprocessing
* Counselling on emotional regulation (anger, anxiety, stress, sleep)
82
What is the pharmacotherapy for PTSD?
First line:
* **SSRI**
Second line:
* Mirtazapine (15mg)
* Amitriptyline (50-75mg)
Third line:
* Phenelzine (45-60mg) +low tyramine diet
83
What is a general description of **adjustment disorder**?
when a persons psychological distress response to one or more stressors becomes severe enough to impair social and other functioning.
84
What are common stressors which may trigger an **adjustment disorder**?
* Workplace problem
* Legal difficulty
* Health crisis
* Interpersonal problems
* Leaving home Retirement
85
What are the classifications of adjustment disorder?
* ...with depressed mood
* ...with anxiety
* **...with mixed anxiety and depression (most common)**
* ...with disturbance of conduct
* ...with mixed disturbance of emotions and conduct ...unspecified
86
What is the treatment for adjustment disorder with anxiety?
**WHERE SEVERE**
* Diazepam 2-5mg for a maximum of 2 weeks
87
What is the epidemiology of anxiety disorders?
About 15% prevalence Higher prevalence in females
88
What are the brain loci associated with anxiety disorders?
* Median frontal cortex
* Amygdala
* Hippocampus
89
What is the core feature of panic disorder?
Recurrent and severe panic attacks:
* **Sudden** **episodes of intense fear or discomfort** accompanied by physical and cognitive symptoms
90
What is a broad description of a panic attack?
Panic attacks are **overwhelming feelings of fear and discomfort**. They reach peak intensity in about 10 mins and last for about half an hour
91
What features are required to diagnose a panic attack?
**At least 4 of the following:**
* **Palpitations**
* Sweating
* Trembling / shaking
* Shortness of breath
* Choking
* Chest pain or discomfort
* Nausea or abdominal distress
* Dizziness
* Chills or heat sensations
* Paraesthesia
* **Derealisation** (feelings of unreality) or depersonalisation (being detached from oneself)
* Fear of losing control or 'going crazy'
* Fear of dying
92
What are the cognitive symptoms of a panic attack?
* **Derealisation** (feelings of unreality) or depersonalisation (being detached from oneself)
* Fear of loosing control or going crazy
* Fear of dying
93
What are the important measures of severity of a panic disorder?
* **Frequency** of attacks
* Intensity of symptoms
* **Level of function between attacks**
94
What is the definition of **agoraphobia**?
Fear of situations where **escape may be difficult** or help would not be available in the event of having panic symptoms or other embarrassing symptoms.
95
What are some common situations that evoke an agoraphobic avoidance response?
* Using public transport
* Being in open spaces
* Being in enclosed public spaces
* Standing in line or being in a crowd
* Being outside of the home alone
96
What is the epidemiology of panic disorder?
Prevalence is about 2.5% Median age of onset is 20-24
97
What is the core feature of social anxiety disorder?
* Marked fear or anxiety of **social or performance situations** where the patient may be scrutinised by others.
* **Anticipatory anxiety** preceding these situations.
98
What are the somatic features of social anxiety?
* Blushing
* Speech block
* Sweating
* Palpitations
* Trembling
* Muscle tension
* Twitching
* Leg weakness
* Breathing difficulties
* Stomach discomfort
* Diarrhoea
* Feeling of faintness
* Buzzing or ringing in the ears
* Dry mouth
* Hot / cold flushes
* Headache
99
What is the epidemiology of social anxiety disorder?
* Prevalence is around 4% Median age of onset is 14
* Twice as prevalent in females
* Males more likely to seek help
100
What is a general description of a specific phobia?
Irrational fear and avoidance of specific objects or situations
101
What are the main categories of phobic stimuli associated with specific phobias?
* Animals (spiders, dogs)
* Natural environment (heights, storms, water)
* Blood, injection, or injuries
* Situations (aeroplane, lifts)
102
What is a general description of generalised anxiety disorder?
**Generalised and persistent** feelings of anxiety that are driven by worries about a number of everyday events or activities such as work, academic performance, the welfare of family members, etc. It takes the form of **anxious anticipation of impending catastrophe** and is **uncontrollable and out of proportion** to the feared event.
103
What are some psychological symptoms of generalised anxiety disorder?
* Restlessness
* Difficulty concentrating
* Feeling that mind has gone blank
* Irritability
* Depersonalisation
* Derealisation
* Sleep disturbances
104
What are some physical symptoms of generalised anxiety disorder?
* Fatigability
* Muscle tension
* Autonomic arousal
* Shortness of breath
* Chest pain
* Stomach discomfort
* Dry mouth
* Paraesthesia
* Dizziness Light-headedness
105
What do you need to diagnose generalised anxiety disorder?
* Symptoms need to be present for **6 months**
* Worries should encompass a **number of activities**
* **At least three** of the following (one in children):
* Restlessness
* Fatigability
* Difficulty concentrating
* Irritability
* Muscle tension
* Sleep disturbance
106
What is the epidemiology of generalised anxiety disorder?
* Around 3% of adults have it
* Females twice as likely
* Diagnosis peaks at 35-45
107
What are some screening questions for GAD, social anxiety, panic disorder, and specific phobia?
* In the past few months have you had worries about things in your life?
* Is it hard to control or stop the worry?
* A panic attack is a sudden surge of fear or anxiety, which can come on for no apparent reason. Have you experienced this before? If so, how often?
* Can you identify objects, places, or social situations that make you feel very anxious?
108
What is the difference between generalised social anxiety and non-generalised social anxiety?
* Generalised social anxiety extends across **numerous social situations**
* Non-generalised social anxiety is specific to one or **just a few social situations**
109
What is the management for Generalised anxiety disorder?
1. Psychological interventions are first line.
This includes psychoeducation and CBT
2. Pharmacotherapy
First line: (SSRI)
* Escitalopram 10mg (up to 20mg)
* Paroxetine 10mg (up to 60mg)
Second line: (SNRI)
* Duloxetine 30mg
* Venlafaxine 75mg
Third line: (TCA)
* Imipramine 25mg
Others:
* Buspirone 5mg orally
* Diazepam 2-5mg
110
What SSRIs are used in Generalised anxiety disorder, and what are their dosages?
* **Escitalopram 10mg (up to 20mg)**
* **Paroxetine 10mg (up to 60mg)**
Other SSRIs are **not TGA approved:**
* Citalopram 10mg (up to 40mg)
* Fluoxetine 10mg (up to 80mg)
* Fluvoxamine 50mg (up to 300mg)
* Sertraline 25mg (up to 200mg)
**\*\*\* Pram's and Tine's - 10mg \*\*\* Line - 25mg \*\*\* Amine -50mg**
111
What is the management of generalised **SOCIAL** anxiety disorder
1. Psychological interventions (psychoeducation and CBT) are first line, but many patients will not adequately respond.
2. Pharmacotherapy SSRI:
* Escitalopram 10mg (up to 20mg)
* Paroxetine 10mg (up to 60mg);
* Sertraline 25mg (up to 200mg)
* If no response to SSRI: Venlafaxine 75mg
112
What is the management of non-generalised **SOCIAL** anxiety disorder
1. Psychological interventions (psychoeducation and CBT) 2. Pharmacotherapy Propranolol 10-40mg taken prior to triggering social situation
113
What is the management of panic disorder?
1. Psychotherapy (psychoeducation and CBT)
2. Pharmacotherapy
* SSRI:
* Escitalopram 10mg (up to 20mg)
* Paroxetine 10mg (up to 60mg)
* If SSRI does not work use SNRI:
* Venlafaxine 75mg
* If venlafaxine does not work use TCA:
* Clomipramine 50-75mg
* Imipramine 50-75mg
114
What is the management of specific phobias?
Pharcotherapy has almost no place in the management of specific phobia. The only acceptable use is where there is a need to manage a specific phobia (such as claustrophobia for MRI) In this case use a single dose of diazepam.
115
What is the DSM-5 criteria for major depression?
**5** or more of the following present during the **same 2-week period** (at least one of the first 2)
1. Depressed mood most of the day, nearly every day (irritable in children)
2. Anhedonia
3. Weight loss (unintentional)
4. Insomnia or hypersomnia
5. Psychomotor agitation of retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or inappropriate guilt
8. Problems thinking or concentrating
9. Recurrent thoughts of death, suicidal ideation with or without a specific plan.
116
What is a general description of persistent depressive disorder (dysthymia)?
Less severe, but more prolonged depressive episode
117
What is a general description of disruptive mood dysregulation disorder?
Chronic, severe, and persistent irritability without overt depressive features.
118
What is melancholic depression?
'**biological**' depression which is less related to external triggers and is more amenable to pharmacological than psychological treatment.
119
What is the survey instrument used to identify melancholia in depression?
The Sydney Melancholia Prototypic Index (**SMPI**)
120
In the SMPI, which items favour melancholia?
* Very low energy
* Depressed mood prevents deriving pleasure from things (humorous things don't lift mood)
* Mood and energy levels worse in the morning
* General loss of interest in things they previously enjoyed
* Can't look forward to anything
* Significant psychomotor retardation
* Significant effects to concentration
* Weight loss
* Depression is far worse than expected for given circumstance
* Early years no more difficult than most people
* Good functioning / relationships when not depressed
* Depressions come out of the blue
121
What are the defining features of psychotic depression?
* Significant psychomotor retardation
* Small bursts of agitation
* Stereotypic movements
* Delusions and (sometimes) hallucinations
122
What are the two types of delusions in psychotic depression?
* Mood congruent (thematically congruent with depressed mood: nihilistic, persecutory)
* Mood incongruent (thematically incongruent with depressed mood: TV communicating with them, people spying on them)
123
What are the key features of non-melancholic depression?
* Predisposing personality factors
* Precipitating environmental factors
* Very responsive to psychological intervention
* Respond better to placebo
124
What personality styles are associated with non-melancholic depression?
* High trait anxiety
* Shy and avoidant
* Sensitive to judgement
* Self focussed
* Highly self critical
* Perfectionistic
125
What is the general hierarchy of treatments for major depression?
1. Lifestyle (SNAPW +drugs and sleep)
2. Social treatments (family psychoeducation, support groups).
3. Psychological OR pharmacological treatments
4. Psychological AND pharmacological treatments (dosage adjustments, augment with lithium / antipsychotics)
5. ECT
126
What is the first line pharmacological treatment for major depression, according to the RANZCP guidelines?
* SSRI
* Citalopram
* Escitalopram
* Fluoxetine
* Fluvoxamine
* Paroxetine
* Sertraline
* NARI
* Reboxetine
* Tetracyclic
* Mirtazapine
* Mianserin
* Melatonergic agonist
* Agomelatine
* NDRI
* Bupropion
127
What is the second line pharmacological treatment for major depression, according to the RANZCP guidelines?
* SNRI
* Desvenlafaxine
* Venlafaxine
* Duloxetine
* Milnacipran
* TCA
* Amitryptyline
* Clomipramine
* Dothiepin
* Imipramine
* Nortriptyline
* Trimipramine
* Doxepin
* Serotonin modulator
* Vortioxetine
128
What is the Third line pharmacological treatment for major depression, according to the RANZCP guidelines?
* MAOI
* Phenelzine
* Tranylcypromine
* Reversible MAOI
* Moclobemide
129
What is the pharmacological treatment for major depression according to the RANZCP guidelines?
**First line**:
* SSRI,
* NARI
* TetraCA
* MA
* NDRI
**Second line**:
* SNRI (greater toxicity)
* TCA
* Serotonin modulator
**Third line**:
* MAOI, reversible MAOI
130
What are the Indications for ECT relevant to major depressive disorder?
**First line**:
* Severe melancholic depression (refusing food /drink)
* High risk of suicide
* High level of distress
* Psychotic depression
* Catatonia
* Previous good response
* Patient's choice
**Not first line**:
* Not responding to several trials of medications including TCA's and MAOIs.
131
What is the Psychological therapy most recommended for major depression?
CBT - formal
132
Why are SNRI's classified as second line in the RANZCP guidelines?
Because of greater **toxicity** in overdose
133
What are the first line treatments for major depression according to eTG?
(**SSRI**) Can't Ever Fucking Fix Sad People. (**SNRI**) Double Down with Venlafaxine and (**OTHER**) Mirtazapine
**SSRI**:
* Citalopram 20mg,
* Escitalopram 10mg,
* Fluoxetine 20mg,
* Fluvoxamine 50mg,
* Sertraline 50mg,
* Paroxetine 20mg
**SNRI**:
* Desvenlafaxine 50mg
* Duloxetine 60mg
* Venlafaxine 75mg
**Other**:
* Mirtazapine 15-30mg
134
What are the second line treatments for major depression according to eTG?
* Agomelatine (25mg)
* Moclobemide (300mg)
* Reboxetine (2-4mg)
135
What are the third line treatments for major depression according to eTG?
* TCAs (25-75mg)
* Mianserin (30-60mg)
* MAOIs
136
What is the treatment for major depression when other treatments fail, according to eTG?
* ECT
* Lithium augmentation
* Liothyroxine (T3 augmentation)
* Atypical antipsychotic augmentation
137
What alternative medicine should be avoided when receiving pharmacotherapy for depression?
**St John's wart -** Can cause **serotonin toxicity** when taken alongside serotonergic anti-depressants.
138
What is the difference between Bipolar I, Bipolar II, and Cyclothymic disorder?
* Bipolar I has **Manic** episodes followed by severe depressive episodes
* Bipolar II has **Hypomanic** episodes followed by severe depressive episodes
* Cyclothymic disorder has **Hypomanic episodes followed by mild** depressive episodes
139
What is the broad diagnostic criteria for Bipolar I
Current or past **manic** state AND a current or past **depressive episode**
140
What it the broad diagnostic criteria for Bipolar II
Current or past **hypomanic** state AND a current or past **depressive episode**
141
What is the duration for manic and hypomanic states
One week for manic four days for hypomanic
142
What are the 7 **criterion B** symptoms for diagnosing mania / hypomania?
**Three or more** (four or more if the mood is only irritable) of the following to a significant degree, and where they are a change from usual behaviour:
* Inflated self-esteem or grandiosity
* Decreased need for sleep (feels rested after 3h)
* More talkative than usual or pressure to keep talking
* Flight of ideas or subjective experience that thoughts are racing
* Distractibility
* Increase in goal-directed activity (or purposeless non-goal-directed activity like pacing)
* Excessive involvement in activities that have high potential for painful consequences (spending, unsafe sex, etc.)
143
What distinguishes Mania from Hypomania?
* Marked impairment
* Hospitalisation
* Psychosis
144
When does psychosis occur in Bipolar I and II
In mania for Bipolar I In depression for Bipolar II
145
What is the most common presentation for Bipolar?
* **Depression**. Most don't present in mania
* Family may initiate consultation for mania (particularly **aggressive mania**)
146
What are some screening questions for Bipolar?
* Do you have periods when you feel more energised or wired?
* So you have never experienced any highs or mood overshoots, then?
147
How will patients describe manic / hypomanic states?
* More productive
* Highly energised
* Playful
* Impatient
* Talking over people
* Feeling invincible
* Verbally indiscrete (criticising boss)
* Need less sleep
* Risk taking
* Increased libido
148
What are the typical delusions associated with Mania?
Delusions of grandeur:
* Special powers,
* Special person,
* Famous person,
* Jesus
149
What is the management of acute mania in bipolar disorder?
**First line**:
* Olanzapine (5mg)
* Risperidone (0.5-1mg)
**Second line**:
* Antispychotics:
* Haloperidol (1.5mg)
* Aripiprazole (10mg)
* Asenapine (5mg twice per day)
* Paliperidol (3mg)
* Quetiapine (50mg twice per day)
* Ziprasidone (40mg twice per day)
* Mood stabilisers:
* Lithium carbonate (750-100mg, check levels after 5-7 days)
* Sodium valproate (200-400mg, check serum level after 3 days)
* Carbamazapine (100-200mg, check serum level after 5-7 days)
**Third line**:
* If not responsive to treatment: Combine antipsychotic with lithium
* ECT
150
What is the management of depression in Bipolar
An antidepressant + a recommended prophylactic medication (**Olanzapine + fluoxetine most common**) **Quetiapine** monotherapy
151
What is the prophylactic management of Bipolar?
**OSCE / non-pham stuff**:
* Broadly based treatment program
* therapeutic alliance,
* specialist referral,
* case management,
* compliance therapy
* Manage comorbidities
* Maintain physical health
* Work with family / carers
**Pharmacological**
**First line**:
* **Lithium** (most common)
* Aripiprazole
* Asenapine
* Olanzapine
* Paliperidone
* Risperidone depot
* Ziprasidone
* **Lamotrigine** (if depression is prominent)
* Carbamazepine
* Sodium valproate
152
What is affective psychosis?
* A typically **episodic** psychosis with a tendency to remit.
* Psychotic symptoms occur **only during peak** severity of the episode
153
What is schizophrenic psychosis?
Chronic psychosis typically associated with **deficits in insight.**
154
What is the prevalence of schizophrenia?
1 in 100 people
155
What is the male to female ratio of schizophrenia?
1.4:1
156
What is the typical age of diagnosis for schizophrenia?
Usually late teens to early 30's.
* Men (18-25)
* Women (25-35)
* Later post-menopause peak \>40)
157
What is the current consensus on the genetic basis for Schizophrenia?
* Multigene inheritance with environmental factors:
* Exponential decrease in risk as biological relationships become more distant
* Severe illness in monozygotic twins associated with higher concordance rates.
158
What is the current consensus on pregnancy and birth factors contributing to the development of schizophrenia?
* Hypoxia at birth can double risk
* Maternal infection (viral) can increase risk (shown by seasonal variation in birthdays.
* Low levels of vitamin D in gestation increase risk
159
What is the current consensus on post-birth environmental factors contributing to the development of schizophrenia?
* Stressful life events accumulated in childhood (abuse, neglect)
* Cannabis (dose-response relationships) especially use before the age of 15.
* Factors work in concert with genetic loading.
160
What neurotransmitters have been implicated in the pathophysiology of schizophrenia?
* **Dopamine (most attention)**
* Serotonin
* Glutamate
* GABA
* Cholinergic neurotransmitters
161
What are the neuropathological correlates of schizophrenia?
* Reduced brain weight and volume, due to increased neuronal density (same number of neurons, smaller space) particularly in the **medial temporal lobe**
* Enlarged lateral ventricles
162
What are the five symptom domains of schizophrenia?
* Positive symptoms
* Negative symptoms
* Disorganisation
* Neurocognitive impairment
* Affective features
163
What are the positive symptoms associated with schizophrenia?
* **Delusions and hallucinations.**
* Often associated with reduced insight.
* **Schneiderian 'first rank' symptoms** such as:
* Passivity phenomena
* thoughts/actions controlled by external force
* Thought broadcast
* Thought withdrawal
* Hearing own thoughts repeated aloud
* Hearing voices discussing patient in the third persons
* Hearing a running commentary of what the patient is doing or thinking
164
What are some common Schneiderian first rank symptoms?
* **Passivity phenomena**
* Thoughts/actions controlled by external force
* Thought broadcast
* Thought withdrawal
* Hearing own thoughts repeated aloud
* Hearing voices discussing patient in the third persons
* Hearing a running commentary of what the patient is doing or thinking
165
What is a delusion?
False beliefs which cannot be shaken by logic or reason AND are not to be expected based on the persons background or culture.
166
What are the negative symptoms associated with schizophrenia?
* Poverty of speech
* Affective blunting
* Reduced motivation
* Reduced energy
* Reduced social engagement
167
What is disorganisation, in regards to it as a symptom domain of schizophrenia?
* Formal though disorder
* Attentional impairment
* Inappropriate affect
* Disorganised behaviour
168
What is neurocognitive impairment in regards to it as a symptom of schizophrenia?
* Poor executive function
* Reduced reaction time
* Short attention span
* Difficulty learning new tasks
169
What is executive function?
Planning and maintaining focus.
170
What are affective features in regards to them as a symptom domain of schizophrenia?
* Manic symptoms (acute psychosis)
* Depression (acute or chronic phase)
* Anxiety and panic (General symptom)
* Instability of mood and perplexity (resembles delirium, indicates good prognosis)
171
What are the stages of schizophrenia?
* Prodrome
* Acute episode
* Residual phase
172
What are the key aspects of the prodromal phase of schizophrenia?
* Depression
* Pervasive sense of anxiety
* Suspiciousness
* Social withdrawal
* Insomnia
173
Why is early intervention important in schizophrenia?
* Because prognosis is worse, the more acute episodes a patient experience.
* Best prognosis is effective treatment of first episode.
174
What are factors which lead to good prognosis in schizophrenia?
* Female sex
* Later onset
* Lower number of acute episodes
* Being married
* Good premorbid functioning
* Positive response to medication
* Onset subsequent to clearly defined stressor
175
What is a general description of Schizophreniform disorder?
Simmilar symptoms to schizophrenia, but duration of the illness **does not exceed 6 months.**
176
What is a general description of Schizoaffective disorder?
Where a person has **psychotic features AND disordered mood**, but no clear relationship exists between them. Schizophrenia + mood disorder which are concurrent or sequential but share **distinct courses.**
177
What is a general description of brief psychotic disorder?
**Sudden** onset psychotic symptoms lasting from **days to weeks** followed by full recovery.
178
What is a general description of delusional disorder?
* Usually has a later age of onset
* Characterised by non-bizarre delusions (not a priori false)
* Common in social isolation and sensory impairment which encourages misinterpretation of the motives of others.
179
What is a general description of substance induced psychosis?
Psychotic symptoms, but there is evidence that these symptoms:
1. Developed **soon** after or during intoxication or withdrawal from a substance
2. The implicated substance is **capable** of producing those symptoms.
AND the symptoms **cannot be better explained** by another type of primary psychotic disorder
**Proximity - Capability - Alternative**
180
What is a general description of psychotic disorder due to another medical condition
Psychotic symptoms, but there is evidence that these symptoms are a direct pathophysiological consequence of another medical condition.
181
What medical conditions have been associated with psychotic disorder due to another medical condition?
* **Encephalopathies**
* **Temporal lobe epilepsy**
* Cushings disease
* Thyroid disease
* **Vitamin B12 deficiency**
* Ovarian cancer
* Small cell lung cancer
* **Hypoglycaemia**
* Hyponatraemia
* Hypercalcaemia
* Hypocalcaemia
* Hypomagnesaemia
* SLE
* Wilson's disease
* **Prophyria**
182
What substances have been associated with substance induced psychosis?
* **Anticholinergics**
* **Dopamine agonists**
* Digoxin
* **Steroids**
* Cimetidine
* Amphetamines
* Cannabinoids
* Narcotics
183
What are the key points of the DSM 5 criteria for the diagnosis of Schizophrenia?
1. Two or more of the following with each present for a significant portion of time during a 1-month period (at least one **symptom**):
* **Delusions**
* **Hallucinations**
* Disorganised speech
* Grossly disorganised or catatonic behaviour
* Negative symptoms.
2. Level of function must be impaired (work, relations, self care)
3. Continuous signs of disturbance persisting for 6-months
4. Schizoaffective disorder and depressive or bipolar disorder have been ruled out.
5. Disturbance not attributable to physiological effects of substances or organic pathology.
6. If pre-existing ASD / communication disorder diagnosis. Schizophrenia is only diagnosed where prominent delusions / hallucinations persist for at least 1 month.
184
What needs to be specified in a schizophrenia diagnosis after the person has had it for one year?
* Episode (first or multiple)
* Stage (acute, partial remission, or full remission)
* Whether catatonia is present
* Current severity (not 100% needed)
185
What is severity measurement of schizophrenic symptoms?
Scale for 0-4 for each symptom for current severity (over previous 7 days)
186
What is the management of prodromal schizophrenia?
* Close monitoring
* CBT
* SSRI
* Omega-3 (EPA- eicosapentaenoic acid)
* Ultra low dose antipsychotics (poor evidence)
187
What is the management for the first psychotic episode in scizophrenia?
* Atypical antipsychotic drugs except **Clozapine or sertindol**.
* Diazepam 5-10mg as required (up to 40mg) for **treatment of anxiety, agitation, insomnia and activation syndrome**.
If there is unacceptable partial response after 6-12 weeks switch to another antipsychotic:
1. Alternative atypical (first line); or
2. Chlorpromazine (200mg up to 800mg), Haloperidol (1.5mg up to 10mg) , or Pericyazine (10mg up to 75mg)
**Parenteral treatment is a last resort.**
188
What is the management for the recovery and relapse phase of schizophrenia?
**Continue pharmacological treatment:**
* 2-years following first episode
* 5-years if relapse occurs
* Consider depot formulations
* Monitor side effects
**Use a broadly based treatment program:**
* Psychoeducation program
* Shared care program with GP
* CBT
* Cognitive remediation
* Employment & social supports
* Education and training assistance
**Monitor physical health:**
* SNAPW Important because of metabolic side effects of antipsychotics
**Involve families and care givers:**
* Family therapy
* Carer assistance programs
* Include family in psychoeducation
189
What is the management of relapse in schizophrenia?
* Consider Depot antipsychotics
* Add lithium if there are affective symptoms (++mania)
190
What is the management for treatment-resistant schizophrenia
* **Clozapine**
* Started at a low dose, increased to 200-600mg per day.
* Need serum monitoring during clozapine treatment
191
What is the required monitoring for clozapine?
**First four weeks**
* ECG
* Regular vitals screening
* Regular cardiac screening (trops, CRP)
**First 18 weeks**
* WBC + neutrophils
**Ongoing:**
* Weight
* BMI
* Waist circumference
* glucose
* lipids
192
What drugs can you not take with clozapine?
* Anything that causes **blood dyscrasias**
* **Carbamazepine**
* Chemo agents
* Any drugs that inhibit or induce CYP1A2 (**smoking can cause increase serum concentration on cessation**)
193
What is the management of schizophrenia with prominent negative symptoms?
**First line**:
* Amisulpride (100-300mg daily)
* Clozapine
* Other atypical + antidepressant (fluoxetine preferred)
**Second line**:
* Clozapine + antidepressant (fluoxetine preferred)
* Clozapine + Iamotrigine (25mg for two weeks. increase 15mg every 2 weeks up to 300mg twice daily)
194
What is the preferred antidepressant used in schizophrenia?
Fluoxetine
195
What is the management of acute dystonias from antipsychotic treatment
**Benzatropine 1-2mg** IV or IM as a single dose
196
What is the management of parkinsonian movement disorders from antipsychotic treatment?
**First line**:
* Benzatropine 0.5-2mg oral, daily
**Second line**:
* Benzhexol 2mg oral, daily (up to 10mg per day in 3-4 doses)
197
What is the management of akathisia from antipsychotic treatment?
**First line**:
* Propranolol 20-40mg oral 3-4 times per day
**Second line**
* Diazepam 2-5mg orally 3 times per day
198
What needs to be done when switching antipsychotic medications? What do you need to be cautious of?
* Dose of first is tapered off and the second is tapered up over a period of two weeks.
* Monitor for breakthrough psychosis.
* Monitor for supersensitivity psychosis upon abrupt cessation (**+++ Clozapine**)
GP Matrix
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CVS55
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Respiratory0
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Gastrointestinal53
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Genitourinary tract0
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Endocrine / metabolic0
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Neurology0
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Ophthalmology0
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Ear, Nose, and Throat0
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Haematology0
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Infections0
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Musculoskeletal21
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