Quesmed wrong answers Flashcards

Question

How is opiate overdose managed?

Answer 1

Naloxone. Naloxone is a lipophilic non-selective and competitive opioid receptor antagonist and is required to reverse opioid overdoses and reverse respiratory depression

Answer 2

De Clerambault's syndrome, otherwise known as erotomania, is a delusional disorder in which the patient has a specific, fixed, false belief that someone else is in love with them. The patient is usually a woman and the person they are fixated upon is usually of a higher social status, despite only a brief or non-existent acquaintance. This is not normally any unusual behaviour or hallucinations accompanying the delusion

Answer 3

Cotard's syndrome is the fixed, false belief that the person themselves is dying or dead

Answer 4

Capgras delusion is the fixed, false belief that a close relative or partner has been replaced by an impostor

Answer 5

Othello syndrome, otherwise known as delusional jealousy, or pathological jealousy, is a form of delusional disorder in which an individual believes their partner is unfaithful, despite the absence of proof. It usually affects males and can result in stalking behaviour or even homicide

Answer 6

Symptoms must be present for over a month and interfering with day-to-day activities before a diagnosis of PTSD can be made. Any shorter than a month and it is diagnosed as an 'acute stress reaction' instead. Though PTSD can present months after the event, as long as symptoms are present for a whole month, interrupting daily activities, a diagnosis can be made.

Answer 7

Delirium tremens (DT) is a severe form of alcohol withdrawal that presents with acute confusion and disorientation, hallucinations which can be visual or tactile (formication - the sensation of crawling insects on or under the skin), autonomic hyperactivity (sweating and htn), and, in rare cases, seizures. Typically occurring around 72 hours after the cessation of alcohol intake and symptoms peak between the 4th and 5th day post withdrawal

Answer 8

1. NICE guidelines suggest offering oral lorazepam as the first-line treatment. - If symptoms persist, or oral medication is declined, offer parenteral lorazepam or haloperidol. For maintenance management of alcohol withdrawal, the following steps are recommended: - Administer Chlordiazepoxide - Ensure adequate hydration with fluids - Provide Anti-emetics to manage nausea - Pabrinex (vit b and c) to replenish vitamins - Refer the patient to local drug and alcohol liaison teams for further support and management.

Answer 9

This occurs when a patient continuously repeats the last syllable of a word or phrase. Often seen in Parkinson's.

Answer 10

Derailment is a type of formal thought disorder where the speech consists of a series of unrelated or remotely related ideas.

Answer 11

Perseveration is a formal thought disorder which manifests with inappropriate and uncontrollable repetitions and responses, such as words and gestures. This is due to a person's inability to shift from one concept or behaviour to another. Hence, a person with perseveration may answer the first question correctly but continues to give the same answers to subsequent different questions. This is seen in several conditions, including psychosis, dementia and organic brain diseases.

Answer 12

Tangentiality is a type of formal thought disorder where the person diverts from the original train of thought to other topics but never returns to the original topic. There are still some associations between the sentences, but they are diverted from the original topic of discussion. This is mainly seen in patients with schizophrenia.

Answer 13

Circumstantiality is a formal thought disorder where the speech consists of many unnecessary and insignificant details as well as digressions but will still return to the original point. This may occur in patients with psychosis or obsessional disorders.

Answer 14

DSMV requires greater than five symptoms, occurring nearly every day for 2 weeks for a diagnosis of mild depression. These symptoms are: 1. Depressed mood or irritability for most of the day, indicated by either subjective report (feels sad or empty) or observation by others (appears tearful). 2. Anhedonia: Decreased interest or pleasure in most activities, most of the day. 3. Significant weight change (5%) or change in appetite. 4. Sleep alterations: Insomnia or hypersomnia. 5. Activity changes: Psychomotor agitation or retardation. 6. Fatigue or loss of energy. 7. Guilt or feelings of worthlessness: Excessive or inappropriate guilt or feelings of worthlessness. 8. Cognitive issues: Diminished ability to think or concentrate, or increased indecisiveness. 9. Suicidality: Thoughts of death or suicide, or formulation of a suicide plan. One of these symptoms must include either (1) depressed mood or (2) loss of interest or pleasure. For a diagnosis of depression, these symptoms must cause the individual clinically significant distress or impairment in social, occupational or other important areas of functioning. The symptoms must also not be a result of substance abuse or another medical condition.

Answer 15

GI upset Anxiety and agitation QT interval prolongation (especially associated with citalopram) Sexual dysfunction Hyponatraemia Gastric Ulcer Cautions: Should be omitted in mania Should be used with caution in children and adolescents Sertraline is best for patients with ischaemic heart disease Should be avoided with anticoagulants as there is an increased risk of bleeding

Answer 16

Tricyclic anti-depressants are a second line medication for depression. They are strongly associated with anti-cholinergic activity. Consequently, the common side effects include: Urinary retention Drowsiness Blurred vision Constipation Dry mouth Cautions: - CI in those with previous heart disease - Can exacerbate schizophrenia - May exacerbate long QT syndrome - Use with caution in pregnancy and breastfeeding - May alter blood sugar in T1 and T2 diabetes mellitus - May precipitate urinary retention, so avoid in men with enlarged prostates - Uses the Cytochrome P450 metabolic pathway, so avoid in those on other CP450 medications or those with liver damage

Answer 17

Restlessness, diaphoresis, clonus, hyperthermia, rigidity, hyperreflexia. *CLONUS and HYPERREFLEXIA help to differentiate from other conditions SSRIs (and bupropion) and amphetamines both increase serotonergic transmission in the brain, which can precipitate serotonin syndrome.

Answer 18

Antipsychotics are dopamine-receptor antagonists, which can decrease dopaminergic transmission, leading to NMS. Clinical features of NMS are similar to that of serotonin syndrome – altered mental state, diaphoresis, tachycardia, rigidity and hyperthermia. However, NMS presents with a relatively gradual onset in days or weeks rather than hours, as in serotonin syndrome. Moreover, patients with NMS generally have normal pupils, hyporeflexia and do not have clonus.

Answer 19

Cluster A personality disorders are psychiatric conditions characterised by odd or eccentric behaviors. They include paranoid personality disorder, characterised by pervasive distrust and suspicion of others; schizoid personality disorder, marked by social detachment and limited emotional expression; and schizotypal personality disorder, defined by a pattern of impaired social interactions and eccentric behaviors. Key investigations involve thorough psychiatric evaluation, detailed patient history, and when necessary, imaging studies like MRI or CT scans to rule out other potential neurological causes. Key management strategies for these disorders typically encompass a combination of psychotherapy (such as cognitive-behavioral therapy) and medication management for associated symptoms such as anxiety, depression, or psychotic symptoms.

Answer 20

- Characterised by a chronic pattern of impaired social interactions, distorted cognitions and perceptions, and eccentric behaviors - Demonstrates inappropriate or constricted affect, and peculiar, eccentric or bizarre behavior - Displays odd thinking and speech, such as magical thinking, peculiar ideas, paranoid ideation, and belief in the influence of external forces - Shares certain cognitive or perceptual distortions with schizophrenia, but maintains a more intact grasp on reality

Answer 21

Bulimia nervosa is a psychiatric disorder characterized by recurrent episodes of binge eating (eating a large amount of food in a short period of time with a sense of loss of control) followed by inappropriate compensatory behaviours to prevent weight gain. These behaviours typically include self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise. Unlike anorexia nervosa, individuals with bulimia nervosa may maintain a normal or slightly above average body mass index (BMI > 17.5).

Answer 22

Psychological symptoms include: - Binge eating: Characterized by a loss of control, consumption of enormous amounts of food with high caloric content, often with a sense of urgency and compulsion - Purging: Binge episodes often lead to feelings of shame and guilt, leading to attempts to 'undo the damage' through behaviours such as induced vomiting, misuse of laxatives or diuretics, and excessive exercise - Body image distortion: Patients may have a distorted perception of their body, often perceiving themselves as overweight despite maintaining a normal or slightly above average weight. Physical symptoms include: - Dental erosion: Resulting from recurrent self-induced vomiting - Parotid gland swelling: Resulting from recurrent self-induced vomiting - Russell's sign: Scarring on the back of the hand or knuckles caused by repeated self-induced vomiting

Answer 23

While no specific laboratory tests diagnose bulimia nervosa, healthcare professionals rely on the following: - A detailed medical history: To evaluate for recurrent episodes of binge eating and compensatory behaviours - A comprehensive physical examination: To identify potential physical signs of bulimia, including dental erosion, parotid gland swelling, or Russell's sign - Psychological assessments: To evaluate for associated psychological conditions and body image distortion

Answer 24

The primary management strategies for bulimia nervosa include: - Specialist referral: All patients diagnosed with bulimia nervosa should be referred to a specialist for ongoing management - Cognitive-behavioral therapy (CBT): CBT is the first-line treatment for bulimia nervosa and focuses on altering destructive eating behaviours and thought patterns, as well as improving body image and self-esteem - U&Es for electrolyte abnormalities

Answer 25

- Excessive potassium loss occurs as a result of repeated self-induced vomiting and laxative use. Excessive vomiting can cause metabolic alkalosis due to loss of hydrochloric acid, which in turn increases renal potassium excretion. symptoms may include muscle weakness, cramps, fatigue and constipation. - Hypocalcaemia is a differential diagnosis here and is associated with long-term misuse of diuretics. Calcium, phosphate and magnesium should be part of the investigations.

Answer 26

1. Acute Mania with Agitation: IM therapy (antipsychotic or benzodiazepine) and potential secure unit admission. 2. Acute Mania without Agitation: Oral antipsychotic monotherapy, potential addition of sedatives or mood stabilisers. Antipsychotics with mood-stabilising properties including Olanzapine, Haloperidol, Risperidone or Quetiapine.

Answer 27

Diagnosis is primarily based on the DSM-5 criteria. - Mania: Requires at least one episode lasting at least a week with at least three associated symptoms (e.g., inflated self-esteem, decreased need for sleep). - Hypomania: Similar to mania but less severe, not causing marked impairment in social or occupational functioning, and lacking psychotic features. - Depression: Requires at least one major depressive episode lasting at least two weeks with at least four associated symptoms (e.g., changes in appetite or sleep, feelings of worthlessness). Bipolar 1 is mania and depression Bipolar 2 is HYPOmania and depression

Answer 28

Long-term maintenance therapy is crucial due to high relapse risk: 1. Mood stabilisers (e.g., Lithium or Valproate) are the cornerstone of treatment. 2. Atypical antipsychotics and anticonvulsants may be used in treatment-resistant cases. 3. High-intensity psychological therapies (e.g., CBT, interpersonal therapy, or couples/family therapy) are recommended.

Answer 29

- A history of self-harm or previous suicide attempts - Other mental health disorder (e.g depression, bipolar disorder) - Male sex - Drug and alcohol abuse - A planned attempt (eg. leaving a note, attempting to hide, making a will) - Poor social support (eg. unemployment, single, living alone)

Answer 30

Most commonly used antidepressants, including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs), work by inhibiting the reuptake of monoamine neurotransmitters such as serotonin, norepinephrine, and dopamine. This increases the concentration of these neurotransmitters in the synaptic cleft, leading to enhanced neurotransmission and improvement in mood.

Answer 31

Clinical features at therapeutic dose - Fine tremor - Dry mouth - Gastrointestinal disturbance - Increased thirst - Increased urination - Drowsiness - Thyroid dysfunction Clinical features in lithium toxicity - Coarse tremor - Muscle weakness - Central nervous system disturbance, which may include seizures, impaired coordination and ataxia, and dysarthria, confusion - Nausea and vomiting - Cardiac arrhythmias - Visual disturbance - Renal impairment

Answer 32

Investigations - Serum lithium levels: This is the gold standard for diagnosing lithium toxicity. - Electrolyte levels: To assess for any electrolyte imbalance. - Thyroid function tests: Given the potential for thyroid dysfunction. - Renal function tests: Given lithium's potential to cause renal impairment. - ECG: To assess for arrhythmias. Management Management of lithium toxicity is largely supportive and often requires specialist input. Key strategies include: - Maintaining electrolyte balance - Monitoring renal function - Seizure control - IV fluid therapy and urine alkalisation, which enhance the excretion of the drug - Benzodiazepines may be used to treat agitation and seizures - Haemodialysis might be required if renal function is poor

Answer 33

In delusions of control, patients believe that an external party is controlling their thoughts or actions. They are most commonly seen in psychosis

Answer 34

Nihilistic delusions encompass a range of negative beliefs, often surrounding death and decay eg the patient believes that they are dead or that the world has ended. They are most common in severe depression

Answer 35

Cotard's delusions are a type of nihilistic delusions. Patients believe that they are dead, or no longer exist. These are most common in psychosis or severe depression,

Answer 36

In persecutory delusions, the patient believes they are at risk of harm from others, despite insufficient evidence. Eg think they are being persecuted or conspired against. These may be seen in psychosis and paranoid schizophrenia

Answer 37

Delusions of grandeur are most closely associated with mania. Patients believe they have highly positive traits, for example being very rich, intelligent or powerful. They believe that they have powers

Answer 38

Delusions are fixed, false beliefs that are maintained despite contradictory evidence. They are a prominent feature of numerous psychiatric conditions, including but not limited to schizophrenia, bipolar disorder, and psychotic depression. Delusions can be classified as bizarre (very strange or highly unusual) or non-bizarre (plausible but incorrect), and mood-congruent (consistent with the individual's emotional state) or mood-neutral.

Answer 39

Patients are convinced they have a physical, medical, or biological problem despite no medical evidence supporting their claim. These delusions can manifest as a wide range of physical symptoms.

Answer 40

Investigations Assessment and investigation of delusions involve: 1. Clinical interview: Comprehensive psychiatric history, including onset, duration, and the impact of symptoms on functioning. 2. Mental state examination (MSE): Evaluation of appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, and judgment. 3. Neuropsychological assessment: To rule out neurocognitive disorders or to assess for any cognitive impairment. Management Management of delusions often involves: 1. Pharmacological treatment: Antipsychotic medication is the mainstay of treatment. The choice of medication depends on the underlying disorder, e.g., atypical antipsychotics for schizophrenia, mood stabilizers for bipolar disorder. 2. Psychotherapy: Cognitive behavioral therapy (CBT) can be beneficial. It involves developing coping strategies and challenging the irrational beliefs. 3. Psychoeducation: Providing information to the patient and their family about the nature and management of the disorder. It can help to improve adherence to treatment and reduce relapse rates.

Answer 41

Cushing's syndrome (usually secondary to corticosteroid use) May present with - Low mood and energy - Delusions - Memory problems, - Weight gain - High blood pressure - Presence of bruises. (may not be comprehensive - taken from a question)

Answer 42

Donepezil Galantamine Rivastigmine

Answer 43

In refeeding syndrome, patients are at risk of low phosphate, magnesium and potassium levels, as well as hyperglycaemia. Prominent U waves are a feature of hypokalaemia and may therefore be seen in refeeding syndrome.

Answer 44

1. Examination: BMI <17.5 kg/m2 (contrast with bulimia nervosa, where there may be many similar features, but the BMI is normal, a key distinguishing feature) Hypotension Bradycardia Enlarged salivary glands Lanugo hair (fine hair covering the skin) Amenorrhoea (hypogonadotropic hypogonadism) 2. Blood results: - Deranged electrolytes ‚typically low calcium, magnesium, phosphate and potassium - Low sex hormone levels (FSH, LH, oestrogen and testosterone) - Leukopenia - Raised growth hormone and cortisol levels (stress hormones) - Hypercholesterolaemia - Metabolic alkalosis, either due to vomiting or use of diuretics

Answer 45

Refeeding syndrome: - A potentially fatal disorder that occurs when nutritional intake is resumed too rapidly after a period of low caloric intake - symptoms may include oedema, confusion and tachycardia - Rapidly increasing insulin levels lead to shifts of potassium, magnesium and phosphate from extracellular to intracellular spaces ‚these need to be replenished Preventative measures include: - The provision of high-dose vitamins (eg. Pabrinex) before feeding commences - Monitoring with daily bloods and replenishing electrolytes early - Building caloric intake gradually with the help of a dietitian ‚ NICE recommends that refeeding is started at no more than 50% of calorie requirement in 'patients who have eaten little or nothing for more than 5 days'

Answer 46

These patients are at higher risk of arrhythmias and an ECG should be performed periodically, especially if they are complaining of cardiac symptoms (eg. palpitations, fainting episodes or dizzy/light-headed spells) - Bradycardia and prolonged QTc are often seen

Answer 47

Only certain SSRIs are used to treat OCD, which are fluoxetine, fluvoxamine, paroxetine, sertraline and citalopram. Citalopram is an off-label drug for OCD.

Answer 48

Clomipramine (TCA) - the only TCA used to treat OCD

Answer 49

An antipyschotic

Answer 50

Section 4 of the Mental Health Act allows for an emergency admission for up to 72 hours. This section is applicable in cases of urgent necessity when it is not practical to wait for the usual process of Section 2 or 3.

Answer 51

Section 5(2) of the Mental Health Act allows a doctor to detain a patient who is already in the hospital for up to 72 hours for assessment. This section is applicable when a patient already in the hospital requires urgent assessment and may be at risk of causing harm to themselves or others. (A&E is classified as a public place so does not fit under this)

Answer 52

This includes heroin, and they exert their effects through acting on the opioid receptors Features are: - Drowsiness - Confusion - Decreased respiratory rate - Decreased heart rate - Constricted pupils - Track marks (needle marks) if the intravenous route has been used; abscesses at injection sites; veins thrombosed and damaged causing difficulties with intravenous access (causing difficulty in

Answer 53

Features include: Agitation Anxiety and irritability Muscle aches or cramps Chills Runny eyes Runny nose Sweating Hypersalivation Yawning Insomnia Gastrointestinal disturbance such as abdominal cramps, nausea, diarrhoea and vomiting Dilated pupils Piloerection Increased heart rate and blood pressure

Answer 54

1. During withdrawal the following drugs may be used to help with symptoms: - Methadone: beware, may cause prolonged QTc - Lofexidine (alpha 2 receptor agonist) - Loperamide (for diarrhea) - Anti-emetics (for nausea) Benzodiazepines (for agitation) --> NICE advises against prescribing opiates during opiate withdrawal, but prefers symptomatic management or use of lofexidine. Detox programmes use methadone and buprenorphine (the latter is a partial agonist of the opiate receptor, so can trigger withdrawal) Relapse can be prevented using neltrexone once detox is complete. Overdose can be managed with naloxone

Answer 55

Cluster C personality disorders are recognized as the "anxious or fearful" disorders and are comprised of three distinct conditions: Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders

Answer 56

The main side effects of valproate can be remembered with the mnemonic "VALPROATE". Vomiting Alopecia Liver toxicity Pancreatitis/Pancytopenia Retention of fats (ie. weight gain) Oedema Anorexia Tremor Enzyme inhibition Valproate is an antiepileptic medication that can be used in bipolar disorder. It blocks voltage-dependent sodium channels to suppress high frequency neuronal firing. It is an inhibitor of CYP hepatic enzymes. Serum levels can be affected with changes in hepatic function and by other drugs that affect the CYP enzyme systems. It is teratogenic and should be avoided in pregnancy where possible.

Answer 57

The MMSE is a quick, 30-point questionnaire used to screen for cognitive impairment and is the most widely used cognitive screening tool. (Other diagnostic tests such as brain imaging (CT or MRI) and laboratory tests may be ordered based on clinical findings and suspicion of specific causes of dementia.)

Answer 58

1. Behavioural variant (60%), characterised by loss of social skills, personal conduct awareness, disinhibition, and repetitive behaviour. 2. Semantic dementia (20%), characterised by an inability to remember words for things, calling them 'thingy.' 3. Progressive non fluent aphasia (20%), where the patient can't verbalise; their speech is laboured and difficult.

Answer 59

Definition ICD-11 Criteria: - Excessive worry and apprehension. - Difficulty controlling worry. - Associated symptoms: Restlessness, muscle tension, fatigue. - Duration: At least 6 months. DSM-V Criteria: - Excessive anxiety and worry about various domains. - Difficulty controlling worry. - Associated symptoms: Restlessness, muscle tension, fatigue, irritability. - Duration: At least 6 months.

Answer 60

First line - low-intensity psychological interventions: - Individual non-facilitated self-help - written/electronic materials that the patient can work through - Individual guided self-help - written/electronic materials that a patient works through with 5–7 weekly or fortnightly face-to-face or telephone sessions (30 minutes each) with a trained practitioner. - Psychoeducational groups - interactive CBT-guided group sessions Second line: for people with GAD and marked functional impairment, or with GAD that has not improved following the above: - High-intensity psychological intervention such as CBT or applied relaxation - Medical management - SSRIs are preferred i.e. sertraline, and if one does not work an alternative can be trialled e.g. escitalopram, paroxetine, or an SNRI (venlafaxine or duloxetine) can be used - In the first week of treatment there may be increased anxiety, agitation, and sleeping problems, and in people aged under 30 years, SSRIs and SNRIs are associated with an increased risk of suicidal thinking and self-harm. Patients under 30 should therefore have a follow-up appointment within 1 week to monitor progress. - Symptomatic management with propranolol for palpitations can also be used.

Answer 61

Panic Disorder, a prevalent anxiety disorder, is characterized by the occurrence of recurrent, unexpected panic attacks, each marked by intense fear or discomfort. These episodes prompt persistent worry about future attacks and may lead to avoidance behaviors, altering one's lifestyle to prevent potential episodes. Onset typically arises in adolescence or early adulthood, and the disorder exhibits a lifetime prevalence of 2-5%. Biological, psychological, and environmental factors contribute to its development.

Answer 62

- Difficulties in breathing. - Chest discomfort. - Palpitations. - Hyperventilation, leading to tingling or numbness in the hands, feet, or around the mouth due to hypocalcemia resulting from increased blood pH and calcium binding to albumin. If extreme, carpopedal spasm (curling of fingers and toes) can occur. - Shaking, sweating, dizziness. - Depersonalization/derealization. - May result in fear of situations where panic attacks occur or lead to agoraphobia. - Development of a conditioned fear-of-fear pattern.

Answer 63

Cognitive Behavioral Therapy (CBT) effective in 80-100% of cases and is the first-line treatment. - Initial education about the nature of panic attacks and fear-of-fear cycles. - Cognitive restructuring and detection of logical flaws. - Interoceptive exposure techniques such as controlled exposure to somatic symptoms (breathing in CO2 and physical exercise). - Treatment of secondary agoraphobic avoidance through situational exposure and anxiety management techniques. Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line drug treatment (second-line to CBT). Clomipramine, a tricyclic with a similar action on serotonin, is also effective, and propranolol can be used as needed for symptomatic management.

Answer 64

Phobias, encompassing specific phobia, social anxiety disorder (SAD), and agoraphobia, represent a cluster of anxiety disorders characterized by excessive and irrational fears. Specific phobia involves intense anxiety triggered by a specific object or situation, leading to avoidance behavior. Social anxiety disorder revolves around a marked fear of social scrutiny and performance situations, impeding daily functioning. Agoraphobia entails anxiety about situations where escape might be difficult or help unavailable. These conditions, distinct in their triggering stimuli, share common features of avoidance and significant impairment in daily life. ICD-11 criteria: Restricted to highly specific situations such as proximity to particular animals, heights, thunder, flying, exposure to blood, etc.

Answer 65

Usually apparent in early adulthood. Leads to avoidance behavior. Phobias of blood and bodily injury can result in bradycardia and hypotension upon exposure. Severity is dependent on the effect on quality of life (e.g., pilots afraid of flying). Always rule out comorbid depression.

Answer 66

- ICD-11 criteria: Fear of open spaces and associated factors like the presence of crowds or the perceived difficulty of immediate easy escape to a safe place, usually home (may occur with or without panic disorder). - Typically begins in 20s or mid-thirties. - Onset may be gradual or precipitated by a sudden panic attack. - Comorbid depression is common (beware of reliance on drugs and alcohol for coping).

Answer 67

- Most common anxiety disorder. - ICD-11 criteria: Fear of scrutiny by others in relatively small groups (as opposed to crowds), resulting in the avoidance of social situations. - Relatively small groups generally consist of around 5-6 people (usually 1-2 is tolerable). - May be specific (public speaking) or generalized (any social setting). - Physical symptoms include blushing, fear of vomiting. - Symptoms include blushing (characteristic), palpitations, trembling, sweating. - Can be precipitated by stressful or humiliating experiences, parental death, separation, chronic stress. - Genetic predisposition is possible. - May lead to alcohol or drug abuse (perpetuating the problem). - Mental state examination: may appear relaxed as the phobic object or situation is not present.

Answer 68

CBT is first-line management for all phobias: - Exposure techniques are the most widely used, aiming for systematic desensitization (using a graded hierarchy approach, for example). - Flooding (exposing someone with a fear of heights to a tower), - Modelling (individual observes therapist interacting with phobic stimulus). If ineffective/severe functional impairment, SSRIs are first-line medical management. Propranolol can be used if somatic symptoms predominate.

Answer 69

The pathophysiology of paracetamol overdose involves the buildup of a toxic substance called NAPQI (N-acetyl-p-benzoquinone-imine). Normally, NAPQI is inactivated by glutathione, but during an overdose, glutathione stores are rapidly depleted, leaving NAPQI unmetabolised and resulting in liver and kidney damage.

Answer 70

Paracetamol overdose can present with a broad range of symptoms including: - No symptoms - Nausea and vomiting - Loin pain - Haematuria and proteinuria - Jaundice - Abdominal pain - Coma - Severe metabolic acidosis

Answer 71

Investigations should include: - Full Blood Count (FBC) - Urea and Electrolytes - Clotting Screen - Liver Function Tests - Venous Blood Gas - Paracetamol level Decisions on treatment are guided by a nomogram which plots paracetamol levels.

Answer 72

The management of paracetamol overdose is dependent on the timing of ingestion, dose, and patient's clinical condition: 1. Ingestion less than 1 hour ago + dose >150mg/kg: Administer activated charcoal 2. Ingestion <4 hours ago: Wait until 4 hours to take a level and treat with N-acetylcysteine based on level 3. Ingestion within 4-8 hours + dose >150mg/kg: Start N-acetylcysteine immediately if there is going to be a delay of ≥8 hours in obtaining the paracetamol level 4. Ingestion within 8-24 hours + dose >150mg/kg: Start N-acetylcysteine immediately 5. Ingestion >24 hours: Start N-acetylcysteine immediately if the patient has jaundice, right upper quadrant tenderness, elevated ALT, INR >1.3 or the paracetamol concentration is detectable 6. Staggered overdose: Start N-acetylcysteine immediately If patients are at increased risk of toxicity following paracetamol overdose (e.g., patient on long-term enzyme inducers, regular alcohol excess, pre-existing liver disease, glutathione-deplete states: eating disorders, malnutrition and HIV), N-acetylcysteine should also be administered immediately. Consider the need for transfer to a liver unit if blood tests are worsening.

Answer 73

The King's College Criteria is used to predict mortality from paracetamol overdose and to identify those patients who would potentially benefit from liver transplantation. Arterial pH - Less than 7.3, irrespective of the grade of encephalopathy Serum creatinine - Greater than 3.4 mg/dL (300 µmol/L), irrespective of the grade of encephalopathy Prothrombin time - Greater than 100 seconds Grade III or IV encephalopathy - Plus either bilirubin greater than 18 mg/dL (300 µmol/L) or international normalized ratio (INR) greater than 6.5

Answer 74

A lack of spontaneous speech.

Answer 75

The patient suddenly halts in their thought process and cannot continue.

Answer 76

Schizophrenia is a severe mental disorder characterised by chronic or relapsing episodes of psychosis. It involves altered perceptions of reality, disordered thinking, and social dysfunction that can affect various aspects of the individual's life.

Answer 77

The pathophysiology of schizophrenia is multifactorial and includes both genetic and environmental factors. 1. Genetic Factors: The risk of developing schizophrenia is significantly increased in individuals with a positive family history, with the risk being proportional to the degree of genetic relationship. For example, the risk is: - 2% with an affected first cousin - 5% with an affected grandparent, aunt/uncle, niece/nephew - 10% if either a parent or sibling is affected - 50% if both parents are affected or an identical twin is affected 2. Environmental Factors: Several environmental factors have been associated with an increased risk of schizophrenia, including: - Childhood trauma, such as poor maternal bonding, poverty, or exposure to natural disasters - Heavy cannabis use in childhood - Maternal health issues, including malnutrition and infections like rubella and cytomegalovirus - Birth trauma, particularly hypoxia and blood loss - Urban living and immigration to more developed countries

Answer 78

Schizophrenia is characterized by: 1. Schneider's first rank symptoms which include: - Audible thoughts (thought echo), Voices arguing or commenting on one's actions - Somatic passivity, Made feelings, impulses, and volitional acts - Thought withdrawal, thought insertion, and thought broadcasting - Delusional perception 2. Negative symptoms that often overlap with features of depressive disorders. These include: - Alogia - Anhedonia - Affective incongruity or blunting - Avolition ICD-10 diagnostic criteria require these symptoms to have been present most of the time during a period of at least one month.

Answer 79

While schizophrenia is primarily a clinical diagnosis based on history and examination, investigations can help exclude organic causes of psychosis. This includes: - Brain imaging (CT/MRI) to rule out structural abnormalities - Blood tests to exclude infectious (e.g.,HIV, syphilis) or metabolic causes (e.g., thyroid function tests) - Drug screening to identify substance misuse

Answer 80

The primary treatment for schizophrenia is pharmacological, with second-generation (atypical) antipsychotics such as risperidone being the first line of treatment. - In acute episodes, sedatives like lorazepam, promethazine, or haloperidol may be used to manage dangerous behaviour. - Clozapine is considered when schizophrenia is resistant to other antipsychotics. Due to its potential lethal side effects, it requires intensive monitoring. - Psychotherapy, such as cognitive-behavioural therapy, is also an essential part of management. Providing support to patients and families and coordinating care with mental health professionals are critical for long-term management.

Answer 81

Prognosis varies significantly among individuals with schizophrenia. Factors associated with a better prognosis include higher IQ/education level, sudden onset, presence of a precipitating factor, a strong support network, and predominance of positive symptoms. According to the rule of quarters: 25% of individuals never have another episode 25% improve substantially with treatment 25% show some improvement 25% are resistant to treatment

Answer 82

- Characterised by a pervasive and enduring pattern of irrational suspicion and mistrust of others - Demonstrates hypersensitivity to criticism and potential slights - Exhibits reluctance to confide in others due to fear of information being used maliciously against them - Often preoccupied with unfounded beliefs about perceived conspiracies against themselves

Answer 83

- Characterised by an enduring pattern of detachment from social relationships and a restricted range of emotional expression - Displays a pervasive lack of interest in or desire for interpersonal relationships, often preferring solitary activities - Shows an emotional coldness, detachment, or flattened affectivity - Often has few, if any, close relationships outside of immediate family

Answer 84

Suicide attempts are a frequent cause of presentation to A&E. There are a number of factors in a patient's history that can indicate an increased risk of going on to complete suicide: - A history of self-harm or previous suicide attempts - Other mental health disorder (e.g depression, bipolar disorder) - Male sex - Drug and alcohol abuse - A planned attempt (eg. leaving a note, attempting to hide, making a will) - Poor social support (eg. unemployment, single, living alone) It is important to elicit a detailed history from these patients in order to perform an adequate risk assessment.

Answer 85

These are beliefs maintained despite overwhelming contradictory evidence. Delusions occur in various psychiatric conditions, including schizophrenia, bipolar disorder, and psychotic depression.

Answer 86

These involve repetitive, stereotypical behaviors that appear purposeful on the surface.

Answer 87

These are recurrent, senseless thoughts or behaviors. While recognized as irrational by the patient, they often feel powerless to resist them.

Answer 88

Involves pathological preoccupation with a single subject or idea.

Answer 89

This condition is marked by the automatic imitation of another person's movements by a patient.

Answer 90

This severe form of depressive retardation leaves patients unable to speak or move while remaining fully conscious.

Answer 91

Ekbom's syndrome is a delusional belief where a patient feels that they are infested with parasites. They often complain of feeling "crawling" in the skin. It can appear as part of a psychotic illness or a secondary organic disease such as B12 deficiency, hypothyroidism and neurological disorders.

Answer 92

Describes the presence of physical symptoms that cannot be explained by a medical condition, drug or other mental health disorder. It is an unconscious process. Common presenting symptoms are gastrointestinal symptoms and abdominal pain, fatigue, weakness and musculoskeletal symptoms. Patients can present with a dramatic range of physical symptoms which can lead to loss of functioning.

Answer 93

A psychiatric condition that results in a presentation of neurological symptoms without any underlying neurological cause (e.g. paralysis, pseudoseizures, sensory changes). It is not an intentional process, and the symptoms are very much "real" to the patient. It is linked to emotional stress.

Answer 94

Patients have excessive concern that they will develop a serious illness despite a lack of evidence. Patients often demand unnecessary tests and investigations, and can be quite debilitated as a result of their constant worrying. Patients with hypochondriasis typically have no or very few symptoms unlike Somatoform disorder where patients experience dramatic physical symptoms and experience a degree of disfunction.

Answer 95

Patients intentionally fake signs and symptoms (e.g. adding blood to urine and complaining of pain) in order to gain attention and play "the patient role".

Answer 96

Patients intentionally fake or induce illness for secondary gain; e.g. drug seeking, disability benefits, avoiding work or prison time.

Answer 97

The main point of distinction here is that symptoms can occur up to 4 weeks after the traumatic event, and if symptoms last longer than one month, then it is post-traumatic stress disorder. ICD-11 Criteria: - Exposure: Direct or indirect to a traumatic event, resulting in intense emotional distress. - Symptoms: Include dissociation, intrusive memories, negative mood, arousal, or avoidance. - Duration: Persists for a brief period, typically between 3 days to 4 weeks post-event. DSM-V Criteria: - Exposure: Actual or threatened death, serious injury, or sexual violence. - Symptoms: Reflect intrusion, negative alterations in mood, dissociation, avoidance, or arousal. - Duration: Occurs within 3 days to 4 weeks post-event. Clinical Features - Rapid onset of intense psychological distress post-trauma. - Symptoms: Intrusive memories, dissociation, heightened arousal, avoidance, and negative mood alterations. - Emotional reactions: Overwhelming anxiety, sense of unreality. - Physiological manifestations: Palpitations, hypervigilance. - Behavioral responses: Efforts to escape reminders. - Duration: Typically three days to four weeks.

Answer 98

The primary difference between acute stress reaction and adjustment disorder is the nature of the stressor. In acute stress reaction, the stressor is typically severe or life-threatening (e.g., witnessing a fatal car accident), while in adjustment disorder, the stressor need not be severe or outside the "normal" human experience (e.g. being made redundant). ICD-11 Criteria: - Stressor Response: Development of emotional or behavioral symptoms due to a stressor. - Intensity: Symptoms are excessive, causing significant distress. - Duration: Symptoms cease within six months after the termination of the stressor. DSM-V Criteria: - Onset: Within three months of stressor initiation. - Distress: Out of proportion to the severity of the stressor. - Impairment: Evident in social, occupational, or academic functioning. Clinical Features - Diverse clinical features reflecting maladaptive responses to stressors. - Mood disturbances: Symptoms of depression, anxiety, or a combination. - Behavioral manifestations: Impaired social or occupational functioning, marked irritability. - Interpersonal disruptions and avoidance behaviors. - Cognitive alterations: Preoccupations with the stressor, persistent negative outlook. - Intensity and persistence disproportionate to stressor severity.

Answer 99

ICD-11 Criteria: - Exposure: Direct or indirect to a traumatic event. - Clusters of Symptoms: Intrusion, avoidance, negative alterations in cognition and mood, arousal, and reactivity. - Duration: Persists for more than six months. DSM-V Criteria: - Exposure: Actual or threatened death, serious injury, or sexual violence. - Symptom Clusters: Intrusion, avoidance, negative alterations in mood and cognition, and arousal. - Duration: Lasts more than one month. Clinical Features 1. Intrusion symptoms: Recurrent distressing memories, nightmares, or flashbacks. 2. Avoidance symptoms: Efforts to avoid trauma-related reminders. 3. Negative alterations in mood and cognition: Persistent negative beliefs, distorted blame, pervasive negative emotions. 4. Arousal and reactivity symptoms: Hypervigilance, exaggerated startle response, concentration difficulties, sleep disturbances. 5. Clinical course marked by persistent symptomatology. 6. Duration: More than one month, often extending beyond six months.

Answer 100

- NICE advises that patient's with mdoerate/severe PTSD is regarded as clinically important, and require referral to secondary care (Psychiatry) for psychological therapy and/or drug treatment. - Trauma-focused cognitive behavioural therapy (CBT) is the first-line psychotherapy, with eye movement desensitisation and reprocessing (EMDR) therapy used in more severe cases - Armed forces veterans with service-related post-traumatic stress disorder can be referred to secondary care more rapidly than civilians (veterans' priority scheme) - PTSD often co-exists with other mental health conditions, such as anxiety, depression and alcohol/substance misuse. As such, appropriate risk assessments for these conditions, such as screening for risk of self-harm/suicide, should also be carried out. If these are pre-existing these should be managed accordingly. - If these present for the first time along with PTSD, or if the patient is declining psychotherapy, medical management with an SNRI (e.g. venlafaxine) or SSRI is recommended.

Answer 101

Cluster B personality disorders are a group of mental health conditions characterized by dramatic, emotional, or erratic behaviors. They include four distinctive disorders: Antisocial, Borderline, Histrionic, and Narcissistic. 1. Antisocial Personality Disorder - Defined by a pervasive pattern of disregard for and violation of the rights of others. - Individuals with this disorder exhibit a lack of empathy and frequently engage in manipulative, impulsive actions. - Manifestations include aggressive, unremorseful behavior, and consistent irresponsibility, which often results in a failure to obey laws and social norms. 2. Borderline Personality Disorder - Characterized by a recurring pattern of abrupt mood swings, unstable personal relationships, and self-image instability. - The propensity towards self-harm is commonly observed in these patients. - Relationships often fluctuate between extremes of idealization and devaluation, a process known as "splitting". - There is often an inability to control temper and manage affective responses appropriately. 3. Histrionic Personality Disorder - Predominantly characterized by attention-seeking behaviors and excessive displays of emotion. Individuals may display inappropriate sexual behaviors. - Their emotional expressions tend to be shallow, dramatic, and often perceived as exaggerated. - They often perceive relationships as being more intimate than they truly are, reflecting a distorted perception of interpersonal boundaries. 4. Narcissistic Personality Disorder - Characterized by a persistent pattern of grandiosity, a strong need for the admiration of others, and a marked lack of empathy. - Individuals with this disorder often display a sense of entitlement and will exploit others to fulfill their own desires. - Tendency to be arrogant and preoccupied with personal fantasies and desires, often at the cost of disregarding others' feelings and needs.

Answer 102

- Persistent lowering of mood and reduced enjoyment or interest in activities. - Lowering of energy levels. - Biological symptoms of depression like poor appetite and disturbed sleep patterns. It's important to distinguish between sleep that is disrupted due to the infant's sleep cycle and sleep disruption stemming from other causes. - Concerns related to bonding with the baby, caring for the baby, and in extreme circumstances, thoughts about harming oneself or the baby.

Answer 103

The Edinburgh Postnatal Depression Scale (EPDS) is a widely accepted screening tool that consists of 10 questions and takes around five minutes to complete. It evaluates the intensity of depressive symptoms over the past seven days. A detailed psychiatric history is essential to understand past episodes of depression or other mental health disorders, previous treatment regimens, and the family history of psychiatric conditions. A complete physical examination and relevant laboratory investigations may be necessary to rule out other potential causes of depressive symptoms, such as hypothyroidism or anemia, especially if the patient presents with atypical symptoms or does not respond to standard treatment.

Answer 104

First-line treatments typically involve self-help strategies and psychological therapies such as Cognitive Behavioural Therapy (CBT) or Interpersonal Therapy (IPT). Pharmacological treatments, such as antidepressants, are considered in cases of high severity or distinct risks. In severe cases, admission to a mother and baby inpatient mental health unit might also be necessary.

Answer 105

Paranoia Delusions Hallucinations Manic episodes Depressive episodes Confusion

Answer 106

Antipsychotic medications Mood stabilisers in some instances Medication should be prescribed with careful consideration of the mother's breastfeeding status and potential for the transfer of drugs to the nursing infant. Additionally, considering the potential risk to the mother or infant, referral to a specialist mother and baby inpatient mental health unit may be necessary. This is particularly crucial when the mother experiences command hallucinations, thoughts of self-harm or suicide, or delusional beliefs regarding the baby's role or identity.

Answer 107

The 3 main symptoms of psychosis are: 1. hallucinations – where a person hears, sees and, in some cases, feels, smells or tastes things that do not exist outside their mind but can feel very real to the person affected by them; a common hallucination is hearing voices 2. delusions – where a person has strong beliefs that are not shared by others; a common delusion is someone believing there's a conspiracy to harm them 3. disordered thinking and speaking - a person's thoughts and ideas come very quickly, which can make their speech fast and confusing

Answer 108

Dyslexia refers to a specific difficulty in reading, writing and spelling. Dysgraphia refers to a specific difficulty in writing. Dyspraxia, also known as developmental co-ordination disorder, refers to a specific type of difficulty in physical co-ordination. It is more common in boys. It presents with delayed gross and fine motor skills and a child that appears clumsy. Auditory processing disorder refers to a specific difficulty in processing auditory information. Non-verbal learning disability refers to a specific difficulty in processing non-verbal information, such as body language and facial expressions. Profound and multiple learning disability refers to severe difficulties across multiple areas, often requiring help with all aspects of daily life.

Answer 109

The severity of the learning disability is based on the IQ (intelligence quotient): 55 – 70: Mild 40 – 55: Moderate 25 – 40: Severe Under 25: Profound

Answer 110

Often there is no clear cause for the learning disability. A family history of learning disability increases the risk. Environmental factors such as abuse, neglect, psychological trauma and toxins can all increase the risk. Certain conditions are strongly associated with learning disability: - Genetic disorders such as Downs syndrome - Antenatal problems, such as fetal alcohol syndrome and maternal chickenpox - Problems at birth, such as prematurity and hypoxic ischaemic encephalopathy - Problems in early childhood, such as meningitis - Autism - Epilepsy

Answer 111

The key to managing learning disability is with a multidisciplinary approach to support the parents and child. This involves: - Health visitors - Social workers - Schools - Educational psychologists - Paediatricians, GPs and nurses - Occupational therapists - Speech and language therapists

Answer 112

It is important to remember that capacity is decision specific, and having learning disability does not prevent patients from being able to make decisions. They may require more time, effort and decision aids to be able to fulfil the criteria. It may take several attempts on different days or at different times of day to be able to make a decision. Capacity becomes more important as they approach adulthood, as most decisions about a child will be made by their parent or guardian. To have capacity a patient must demonstrate the ability to: - Understand the decision that needs to be made - Retain the information long enough to make the decision - Weight up the options and the implications of choosing each option - Communicate their decision

Answer 113

ICD-11 describes schizoaffective disorder as having an illness which has diagnostic features both of schizophrenia and of a major affective disorder (manic, mixed or moderate/severe depression) occurring simultaneously. The symptoms need to persist for one month.

Answer 114

These can be divided into major depressive episode, manic episode, mixed episode and schizophrenia type symptoms. 1. Major depressive episode Five of the following symptoms should be present for at least two weeks to diagnose a major depressive episode. One symptom must be either depressed mood or loss of interest or pleasure: - Depressed mood. - Decreased pleasure in activities. - Weight loss or weight gain or appetite change. - Insomnia or hypersomnia. - Psychomotor agitation or retardation. - Fatigue. - Feelings of guilt or worthlessness. - Decreased concentration. - Recurrent thoughts of death or suicidal notions. 2. Manic episode Persistently elevated or irritable mood for at least one week. Three of the following need to be present (or four if the patient has an irritable mood): - Inflated self-esteem or grandiosity. - Reduced need for sleep. - Pressure of speech. - Flight of ideas and racing thoughts. - Easily distracted. - Increase in goal-directed activity with psychomotor agitation. - Excessive involvement in high-risk activities - eg, shopping sprees. 3. Mixed episode Features of both manic episode and major depressive episode are present - but only for one week. 4. Schizophrenia symptoms Two or more of the following are present during one month of the illness: - Delusions - if bizarre, no other symptoms are required to make the diagnosis. - Hallucinations - if in the form of a running commentary or two voices, no other symptoms are necessary to make the diagnosis. - Speech abnormalities - eg, incoherent speech and/or speech derailment. - Behavioural abnormalities - eg, disorganised or catatonia. - Negative symptoms - eg, apathy or lack of emotions.

Answer 115

Bipolar disorder features alternating episodes of mania or hypomania and depression. (mood disorder) In contrast, schizoaffective disorder blends mood disorder symptoms (depression, mania, or both) and psychotic symptoms (like hallucinations and delusions).

Answer 116

Electroconvulsive therapy (ECT) or electroshock therapy (EST) is a psychiatric treatment where a generalized seizure (without muscular convulsions) is electrically induced to manage refractory mental disorders. Typically, 70 to 120 volts are applied externally to the patient's head, resulting in approximately 800 milliamperes of direct current passing between the electrodes, for a duration of 100 milliseconds to 6 seconds, either from temple to temple (bilateral ECT) or from front to back of one side of the head (unilateral ECT). However, only about 1% of the electrical current crosses the bony skull into the brain because skull impedance is about 100 times higher than skin impedance. Aside from effects on the brain, the general physical risks of ECT are similar to those of brief general anesthesia. Immediately following treatment, the most common adverse effects are confusion and transient memory loss. Among treatments for severely depressed pregnant women, ECT is one of the least harmful to the fetus. ECT is often used as an intervention for major depressive disorder, mania, and catatonia. The usual course of ECT involves multiple administrations, typically given two or three times per week until the patient no longer has symptoms. ECT is administered under anesthesia with a muscle relaxant. ECT can differ in its application in three ways: electrode placement, treatment frequency, and the electrical waveform of the stimulus. These treatment parameters can pose significant differences in both adverse side effects and symptom remission in the treated patient. Placement can be bilateral, where the electric current is passed from one side of the brain to the other, or unilateral, in which the current is solely passed across one hemisphere of the brain. High-dose unilateral ECT has some cognitive advantages compared to moderate-dose bilateral ECT while showing no difference in antidepressant efficacy.

Answer 117

- Benzodiazepines are indicated for the short-term relief (two to four weeks only) of anxiety that is severe, disabling, or causing the patient unacceptable distress, occurring alone or in association with insomnia or short-term psychosomatic, organic, or psychotic illness. - The use of benzodiazepines to treat short-term ‘mild’ anxiety is inappropriate. - Benzodiazepines should be used to treat insomnia only when it is severe, disabling, or causing the patient extreme distress.

Answer 118

Before a hypnotic is prescribed the cause of the insomnia should be established and, where possible, underlying factors should be treated. However, it should be noted that some patients have unrealistic sleep expectations, and others understate their alcohol consumption which is often the cause of the insomnia. - Short-acting hypnotics are preferable in patients with sleep onset insomnia, when sedation the following day is undesirable, or when prescribing for elderly patients. - Long-acting hypnotics are indicated in patients with poor sleep maintenance (e.g. early morning waking) that causes daytime effects, when an anxiolytic effect is needed during the day, or when sedation the following day is acceptable. Hypnotics should not be prescribed indiscriminately and routine prescribing is undesirable. They should be reserved for short courses in the acutely distressed. Tolerance to their effects develops within 3 to 14 days of continuous use and long-term efficacy cannot be assured. A major drawback of long-term use is that withdrawal can cause rebound insomnia and a withdrawal syndrome. Where prolonged administration is unavoidable hypnotics should be discontinued as soon as feasible and the patient warned that sleep may be disturbed for a few days before normal rhythm is re-established; broken sleep with vivid dreams may persist for several weeks.

Answer 119

Transient insomnia may occur in those who normally sleep well and may be due to extraneous factors such as noise, shift work, and jet lag. If a hypnotic is indicated one that is rapidly eliminated should be chosen, and only one or two doses should be given. Short-term insomnia is usually related to an emotional problem or serious medical illness. It may last for a few weeks and may recur; a hypnotic can be useful but should not be given for more than three weeks (preferably only one week). Intermittent use is desirable with omission of some doses. A short-acting drug is usually appropriate. Chronic insomnia is rarely benefited by hypnotics and is sometimes due to mild dependence caused by injudicious prescribing of hypnotics. Psychiatric disorders such as anxiety, depression, and abuse of drugs and alcohol are common causes. Sleep disturbance is very common in depressive illness and early wakening is often a useful pointer. The underlying psychiatric complaint should be treated, adapting the drug regimen to alleviate insomnia. For example, clomipramine hydrochloride or mirtazapine prescribed for depression will also help to promote sleep if taken at night. Other causes of insomnia include daytime cat-napping and physical causes such as pain, pruritus, and dyspnoea.

Answer 120

1. Benzodiazepines used as hypnotics include nitrazepam and flurazepam which have a prolonged action and may give rise to residual effects on the following day; repeated doses tend to be cumulative. - Loprazolam, lormetazepam, and temazepam act for a shorter time and they have little or no hangover effect. Withdrawal phenomena are more common with the short-acting benzodiazepines. - If insomnia is associated with daytime anxiety then the use of a long-acting benzodiazepine anxiolytic such as diazepam given as a single dose at night may effectively treat both symptoms. 2. Zolpidem, and zopiclone Zolpidem tartrate and zopiclone are non-benzodiazepine hypnotics (sometimes referred to as Z-drugs), but they act at the benzodiazepine receptor. They are not licensed for long-term use; dependence has been reported in a small number of patients. Both zolpidem tartrate and zopiclone have a short duration of action. 3. Clomethiazole Clomethiazole may be a useful hypnotic for elderly patients because of its freedom from hangover but, as with all hypnotics, routine administration is undesirable and dependence occurs. 4. Antihistamines such as promethazine hydrochloride are on sale to the public for occasional insomnia; their prolonged duration of action can often cause drowsiness the following day. The sedative effect of antihistamines may diminish after a few days of continued treatment; antihistamines are associated with headache, psychomotor impairment and antimuscarinic effects. 5. Alcohol - Alcohol is a poor hypnotic because the diuretic action interferes with sleep during the latter part of the night. Alcohol also disturbs sleep patterns, and so can worsen sleep disorders. 6. Melatonin - a pineal hormone; it is licensed for the short-term treatment of insomnia in adults over 55 years; and for the short-term treatment of jet-lag in adults. Elderly - Benzodiazepines and the Z–drugs should be avoided in the elderly, because the elderly are at greater risk of becoming ataxic and confused, leading to falls and injury. Dental patients - Some anxious patients may benefit from the use of hypnotics during dental procedures such as temazepam or diazepam. Temazepam is preferred when it is important to minimise any residual effect the following day.

Answer 121

Loss of cardiac muscle (presents as worsening exercise tolerance). On examination there may be evidence of mitral valve prolapse with a pan systolic murmur and click which is a very common finding in anorexia and is caused by loss of cardiac muscle with the mitral valve remaining the same size.

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