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VIVA Prep

Organic Pathology
Questions

What
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What
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do you understand by the term delirium


Acute, fluctuating change in mental status
Globally impaired cognition and impaired awareness/consciousness
are the core clinical features of delirium?
C: conscious state is disturbed, cognitive impairment, course is
fluctuating
Disordered thinking: slow, irrational, rambling, incoherent ideas
Euphoric, fearful, depressed or angry: labile mood
Language impairment: speech is reduced, repetitive and disruptive
Illusions/delusions/hallucinations: tactile or visual (auditory
suggests psychosis)
Reversal of sleep-awake cycle: may be drowsy by day, hypervigilant
at night
Inattention: poor attention
Unaware: disorientation
Memory deficits: often marked
are the most common causes of delirium?
Systemic infections: UTI, pneumonia, wounds, IV lines
Intracranial infection: encephalitis, meningitis
Drugs: opiates, anticonvulsants, L-dopa
Alcohol/drug withdrawal
Metabolic: hypoglycaemia, hyper/hyponatraemia, anaemia,
malnutrition, liver failure
Hypoxia: respiratory or cardiac failure
Vascular: stroke, MI
Head injury: intracranial pressure, SOL
Epilepsy: post-ictal state
Nutritional: thiamine or B12 deficiency
do you understand by the term dementia?
Syndrome encompassing progressive deficits in several cognitive
domains resulting in significant impairment in social or occupational
functioning

Clinical
Features

Risk Factors

Alzheimers (6080%)
Insidious onset of
symptoms;
Initial forgetfulness
profound memory
impairment;
Dysphasia,
dyspraxia and
personality change;
Increasing age
(>65);

Vascular (10%)
Sudden onset;
Focal neurological
signs;

Age >60;
Obesity;

Lewy Bodies
(10%)
Visual
hallucinations
(small
children/animals);
Spontaneous motor
parkinsonism;
Fluctuation in
mental state;
Increasing age
(>60);

Family history (2550% in 1st degree


relatives);
Downs syndrome;
Causes

Hypertension;
Tobacco smoking;

Family history of
PD;

Amyloid hypothesis
Stroke;
Lewy bodies found
neuritic plaques;
in substantia nigra,
Tau protein
locus coeruleus;
neurofibrillary
tangles;
What do you understand by the term pseudodementia?
o Syndrome in elderly patients in which they exhibit symptoms
consistent with dementia, with the underlying cause being
depression
What do you understand by the term confabulation?
o Production of fabricated, distorted or misinterpreted memories
about oneself or the world, without the conscious intention to
deceive. Most commonly found in Alzheimers dementia or Korsakof
syndrome.
In an elderly patient, how would you diferentiate between depression
and dementia?
o Dementia is a gradual decline in cognitive function. There may be
lability of afect, and impaired language.
o Pseudodementia of depression is a subacute presentation, with a
stable depressed afect and unimpaired language.
Parkinsons disease
o Masked facies, aprosody, dysarthria
o Bradyphrenia (slow to think/respond), late finding of dementia
o Personality change, decreased spontaneous speech, depression,
sleep disturbances, anxiety
o Depression can occur in 50%
o Hallucinations and delusions occur in 50%
o Delirium and dementia are late stage findings
Epilepsy
o Ictal psychosis
Hours to days (brief), altered consciousness, automatisms,
paucity of speech
o Post-ictal psychosis
Follows a nonpsychotic period after the seizure (hours to
days)
Delusions, manic/depressive symptoms
o Inter-ictal psychosis
Paranoid delusions, auditory hallucinations, afective
symptoms
Last from days to weeks
Hypothyroidism
o Depression, slow speech
Hyperthyroidism
o Irritability, agitation, anxiety (manic features)

o Depressive features
o Emotional lability
o Psychosis paranoid delusions, rarely visual/auditory hallucinations
Multiple sclerosis
o Psychosis occasionally seen in early MS
o Odd sensations of patch of wetness or burning, should distinguish
from tactile hallucinations
o Dementia is common in end-stage MS
Systemic lupus erythematosus
o Organic psychosis occurs in 5% of patients, usually within first year
of diagnosis
Delusions and hallucinations (visual, tactile)
o Cognitive deficits
Deficits in short/long term memory and impaired judgment
May eventually progress to dementia
o Depression
Most common psychiatric symptom
Acute onset, reflects patients reaction to chronic illness and
lifestyle change

Walkthrough
1. Assess medical stability
a. In hospital: check obs charts, particularly BP and temperature
2. Risk assessment
a. Risk of harm to self/others (delusions, frightening hallucinations)
b. Make sure patient has no access to weapons
3. Collateral history
a. Ask nursing staf (ward)
b. Check case notes (ward/GP) look for history of dementia,
medications, reason for admission
4. History (most likely uncooperative) take from collateral
a. PC
i. Fluctuating course + acute presentation
ii. Incomprehensible speech
iii. Reversal of sleep-wake cycle
iv. Reporting strange beliefs (delusions) or hallucination
b. PMH
i. Thyroid dysfunction
ii. CVD (stroke/MI)
iii. Recent surgeries, recurrent infection (systemic sepsis)
iv. Dementia, depression
c. Medications
i. Anticholinergics
ii. Psychotropic drugs
d. Drug and alcohol
i. History of abuse (withdrawal)
5. MSE
a. A: inappropriately dressed
b. B: agitation
c. C: language impairment, looseness of associations, delusions
d. A: Anxious, irritable mood, labile afect
e. P: Visual, frightening hallucinations

f.

C: language impairment, inattention, disorientation, memory


impairment
6. Investigations
a. Stroke CT/MRI
b. MI ECG
c. Systemic infection CBE (raised WCC/CRP), chest X-ray, urinalysis
d. Thyroid abnormalities TFTs
e. Alcohol abuse/withdrawal LFTs, CBE (macrocytosis)
f. Hypo/hypernatraemia electrolytes
7. Management
a. General orientate patient
i. Return patient to a secure location (room)
ii. Have the time, date and location written down
iii. 1:1 nursing, frequent observation
b. Acutely agitated low dose olanzapine (2.5 mg oral)
c. Treat underlying cause

Substance Abuse
Questions

What clinical symptoms define substance dependence?


o Over a 12 month period, impairment or distress caused by > 3 of
following
Tolerance
Withdrawal
Taking substance in larger amounts or longer than intended
Limited control over use
Increased time spent obtaining or recovering from substance
use
Forgoes social, occupation or recreational activities
Keeps on using despite problems
What are the CAGE questions and what is their value in the clinical
setting
o Have you ever felt the need to Cut down on substance use?
o Do you get Annoyed at criticism of your substance use?
o Do you ever feel Guilty about your substance use?
o Do you ever take an Early morning drink to get the day started or to
eliminate the shakes?
o Screening test: one or more positive answers means probable
alcohol abuse/dependence
What are the clinical features of alcohol withdrawal and how do they difer
from Delirium Tremens?
o Withdrawal
Autonomic
Tachycardia
Sweating
Tremor
Anorexia, nausea, vomiting
Insomnia
CNS
Seizures
Agitation
Confusion
Hallucinations
o Delirium tremens
Gross tremors
Fluctuating levels of agitation
Tactile hallucinations
Disorientation and impaired attention
What are the common medical and psychiatric complications of abusing
the following
o Psychostimulants
o Cannabis
o Narcotics
o Benzodiazepines
o Solvents

Walkthrough
1. Assess medical stability

2.

3.
4.

5.

6.

a. Dehydration electrolytes, BP, pulse


b. IV fluids
Risk assessment
a. When intoxicated, suicidal or homicidal ideation, previous attempts
b. Access to firearms at home
c. Concealed weapons
Collateral history
History
a. CAGE
i. Cut down
ii. Annoyed
iii. Guilty
iv. Early morning drink
b. Dependence
i. Solitary drinking
ii. Violence associated with drinking
iii. Defensive or hostile when confronted about alcohol
iv. Daily or frequent drinking needed to function
v. Neglect of food intake, physical appearance and hygiene
c. Withdrawal
i. Tremor, sweating, agitation, sleep disturbance
ii. Hallucinations
iii. Seizures
iv. Delirium tremens, confusion, delusions, autonomic
hyperactivity
d. Past psychiatric history
i. Previous admissions
ii. Previous diagnoses, medications, compliance etc
iii. Problems with the law
e. Past medical history
i. Liver disease
f. Family history
i. Alcoholism or alcoholic hepatitis, cirrhosis
Investigations
a. Withdrawal charts
b. LFTs
c. CBE macrocytosis (more chronic problem)
d. Breath-alcohol/blood alcohol (worried about overdose)
Management
a. Immediate
i. Paracetamol headache
ii. Metoclopramide nausea/vomiting
b. Withdrawal
i. De-escalation if aggressive detainment if suicidal or
aggressive
ii. Diazepam
1. Mild 5-10mg QID,
2. If AWS > 15, 20 mg every 2 hours until AWS < 10
iii. Thiamine
1. 300 mg IM/IV for 3-5 days, then 300 mg orally daily for
several weeks
c. Long-term

i. Naltrexone 50 mg orally daily, blocks efect of endogenous


opioids less craving
ii. Acamprosate
1. Inhibits GABA in CNS (mimics efects of alcohol)
reduces voluntary ingestion of alcohol
iii. DASSA
1. Education about alcohol dependence
2. Involve family members
iv. OT to help patients return to previous level of function
v. Support groups (AA, family/group therapy)
vi. CBT changes attitudes and beliefs to develop other
strategies to handle underlying problems

Psychosis
Questions

How would you define the term psychosis?


o Significant impairment in perception of reality with grossly
disorganised behaviour
What are the clinical features of psychosis?
o Disturbances of perception hallucinations
o Disturbances of thought content delusions
o Disturbances of thought organisation formal thought disorder
o Disturbances of motor function - catatonia
What do you understand by the term formal thought disorder?

Inability to communicate thoughts and ideas in a logical and


ordered manner
List some common terms used to describe formal thought disorder and
explain what these terms mean
o Desultory
Looseness of associations
Intact grammar and syntax
o Transitory
Derailments, fusion, substitutions, omissions
Disturbed grammar and syntax
o Drivelling
No correct grammar or syntax
Word salad
List some typical clinical manifestations of catatonia
o State of increased muscle tone at rest, abolished by voluntary
activities
o Execution of movements
Catatonic mutism, staring, catalepsy, rigidity
o Interaction with others
Echolalia, echopraxia
Waxy flexibility
Catatonic opposition/negativism
What are the most important diferential diagnoses of a first presentation
with psychosis?
o Drug-induced
o Schizophrenia
o Bipolar afective disorder
o Depression
o Delirium
Which illegal psychoactive substances are most commonly associated with
drug-induced psychosis in Australia?
What are the most important diferential diagnoses of recurrent psychotic
episodes?
o Poor compliance
o Misdiagnosis
o Epilepsy
o Drug-induced
What are the main symptom domains of Schizophrenia?
o Positive
Delusions
Hallucinations
Disorganised speech and behaviour
o Negative
Blunted afect
Alogia
Avolition
What clinical features would you see in a person with prodromal
schizophrenia?
o

Negative symptoms with/without attenuated positive symptoms


(unusual perceptual experiences) or brief instances of positive
symptoms that spontaneously remit
List some of the epidemiological factors associated with Schizophrenia.
o Prevalence: 0.5-1%
o M:F = 1:1
o Mean age of onset: females 27, males 21
o 50% concordance in monozygotic twins, 40% with both parents,
10% first degree
List some typical neuropathological abnormalities, which can be found in
the brains of people with schizophrenia.
o Larger ventricles, decreased brain volume in prefrontal and
temporal areas
Prefrontal associated with increased severity of psychotic
symptoms
o Anatomic abnormalities in white-matter tracts
Which neurotransmitter systems are thought to be involved in the
pathophysiology of schizophrenia?
o Excess dopamine in the limbic system positive symptoms
o Depletion of dopamine in the frontal lobe negative symptoms
What are the reasons for the high medical comorbidity and reduced
lifespan associated with Schizophrenia?
o Less likely to seek medical help
o Less likely to manage their medications/compliance
o Poor personal care
o Small proportion of patients will commit suicide
o

Mood Disorders
Questions

What are the main clinical symptom domains of depressive disorders?


o Mood depressed mood, anhedonia
o Psychomotor agitation, retardation, reduced flow and volume of
speech, poor concentration
o Cognitive negative triad (self, world, future)
o Neurovegetative disturbances to appetite, sleep, libido, diurnal
mood variation

What are the main clinical symptom domains of bipolar disorders?


o Mood elation, euphoria, irritability, lability
o Psychomotor energetic, impulsivity, flight of ideas, pressured,
rapid speech, distractibility, inattention
o Cognitive self (grandiose), world (expansive), future (optimistic),
mood-congruent delusions
o Neurovegetative decreased need for sleep, increased libido
What is the diference between Bipolar I and Bipolar II, according to DSM
V?
o Bipolar I
History of a single or recurrent manic +/- hypomanic or MDEs
o Bipolar II
History of both MDE + hypomanic episodes
What are the clinical features for mixed episode and what is its clinical
significance?
o Concurrent presence of both depressive and manic symptoms
Manic or hypomanic + 3 or more depressed symptoms
Depressive episode + 3 or more manic symptoms
o Mixed features signal bipolarity
How is mania diferent from hypomania?
o Hypomania is same except
Duration: at least 4 days (rather than 1 week)
No psychotic symptoms
No hospitalisation
Unequivocal change in functioning, but not severe enough to
cause marked impairment in functioning
How is an Adjustment Disorder diferent from depressive disorders?
o Clinical significant emotional or behavioural symptoms in response
to an identifiable stressor occurring within 3 months of its onset and
not persisting beyond 6 months upon its termination
What do you understand by the term Dysthymic Disorder?
o Depressed mood plus 2 other symptoms
Poor appetite or overeating
Insomnia or hypersomnia
Fatigue
Poor concentration
Feelings of hopelessness
Low self-esteem
o For most days over at least 2 years, during which no asymptomatic
periods have exceeded 2 months
What do you understand by the term mood-congruent delusions?
What medical conditions are typically associated with depression?
o Any chronic illness
o Post-MI
o Thyroid dysfunction
o MS
o SLE
o Parkinsons Disease
Which body systems have been associated with the aetiopathogenesis of
mood disorders?

List some of the brain structures and functions, which have been
associated with aetiopathogenesis of mood disorders.
List some epidemiological risk factors for developing a mood disorder
o Sociodemographic factors weak correlation
Separation, socioeconomic status, physical activity, adiposity
o Life stressors
Early life stress, early parental death, social isolation nonmelancholic MDD
Disruption in biorhythm, negative and positive stress
bipolar
o Family history
BD: MZ 40%, DZ 10%
MDD: MZ 30%, DZ 20%

Walkthrough
Depression
1. Assess medical stability
a. Check for any signs of self-harm (lacerations)
2. Risk Assessment
a. Risk of harm to self/others
b. Make sure patient has no means of self-harm (razor blades)
3. Collateral history
a. Ask nursing staf (ward)
b. Check case notes (ward/GP)
c. Ask referral/family member
4. History
a. Cardinal features
i. Constant depressed mood over 2 weeks
ii. Anhedonia
iii. Fatigue
b. Melancholic features (moderate/severe)
i. Anhedonia
ii. Feelings of guilt
iii. Decreased sleep
iv. Anorexia, weight loss (>5% body weight)
v. Diurnal mood variation
c. Psychotic features (severe)
i. Delusions (poverty, nihilism)
ii. Auditory hallucinations
d. Past psychiatric history
i. Previous diagnoses (+post-partum)
ii. Previous medications + compliance + efectiveness + side
efects
e. Past medical history
i. Hypothyroidism, SLE
f. Family history
i. Depression
g. Developmental
i. Traumas, stresses
h. Drug
i. Substance abuse to cope or that exacerbates depression

ii. Withdrawal
5. MSE
a. Appearance
i. Evidence of self-neglect
b. Behaviour
i. Slumped posture
c. Conversation
i. Tone: decreased prosody
ii. Rate: slowed speech
iii. Content: nihilistic/poverty delusions
iv. Normal thought form
d. Afect: depressed, restricted range, mood-congruent
e. Perception
i. Hallucinations: uncommonly auditory, self-deprecatory
f. Cognition
i. May be impaired attention/concentration
g. Insight
i. Should be preserved insight
6. Management
a. Detain if suicide risk
b. Severity
i. Mild CBT
ii. Moderate CBT + SSRI
iii. Severe CBT + SSRI + ECT
c. Identify support network
i. Involve family + close friends
d. Organise activities
i. Exercise therapy
ii. Occupation
Bipolar Affective Disorder
1. Assess medical stability
a. Bipolar risky behaviour, screen for any obvious injuries +
appropriate treatment
2. Risk assessment
a. Depressive episode suicidal ideation
b. Manic episode aggression
c. Check for weapons, room positioning etc
d. If acutely agitated, consider giving low-dose olanzapine (2.5mg oral)
3. Collateral history
a. Family
b. Referral
c. Case notes
d. Nursing staf (ward)
4. History
a. PC
i. Frustration
ii. Irresponsibility + erratic uninhibited behaviour
iii. Racing of thoughts
iv. Increased activity with weight loss and increased libido
v. Decreased need for sleep
b. Atypical depression
i. Hypersomnia + hyperphagia

ii. Family history of bipolar


iii. Early onset
iv. Recurrent
v. Post partum
c. PMH
i. History of bipolar disease
ii. Medications efectiveness, compliance, side efects
iii. History of depression, misdiagnosed as depression
d. Family history
i. Higher chance with one afected 1st degree (4-24%)
ii. Both parents 75%
e. Drug history
i. Drug and alcohol abuse are risk factors
5. MSE
a. B: irritable
b. C: grandiosity, increased rate of speech, flight of ideas
c. A: elevated afect, labile
d. P: hallucinations
e. C: distractibility
f. I: poor insight
6. Management
a. De-escalate before attempting sedation
b. Sedate with atypical antipsychotic
c. Detain under mental health act if risky
d. Prescribe lithium + educate on toxicity, side efects week check
on serum levels
e. Organise family meeting to discuss warning signs of relapse
f. Organise social worker to manage finance
g. Patient should return regularly for kidney and thyroid function tests
(lithium)
h. Educated on sleep-wake cycle maintenance less manic episodes

Personality Disorder and Related Spectrum


Questions

What do you understand by the terms personality, personality traits


and personality disorder?
o Personality disorder
Inner experience and behaviour deviates markedly from
expectations of the individuals culture
Manifested in two or more of the following: cognition, afect,
interpersonal functioning, impulse control
How would you go about explaining the concept of personality disorder to
a patient?
o No pathology, but rather the result of how you have coped and
responded to your upbringing and stresses in life
List the Personality Disorders and describe the core clinical feature of each
o Cluster A low reward dependence + odd beliefs, awkward social
interaction
Paranoid suspicious, unforgiving
Schizoid apathetic, flat afect
Schizotypal odd beliefs, eccentric behaviour
o Cluster B high novelty seeking
Borderline
Histrionic attention-seeking, provocative, dramatic
Narcissistic conceited, arrogant, lacks empathy, envious
Antisocial law-breaking, lack of remorse, reckless disregard
for safety (self/others)
o Cluster C high harm avoidance
Avoidant avoids relationships, scared of rejection, selfdeprecating
OCPD perfectionist, stubborn, preoccupied with work
Dependent feels helpless alone, seeks companionship,
requires reassurance for decisions

Advantages and disadvantages of DSM-V classification of personality


disorders
What do you understand by the term psychopathy and what are its core
features?
o Variant of antisocial personality disorder
o Lack of anxiety or fear
o Bold interpersonal style that may mask maladaptive behaviours
o Attention seeking
What are the core features of borderline personality disorder?
o Afective instability, intense anger
o Behavioural suicidal, impulsive behaviour
o Cognitive transient paranoid or dissociative experiences
o Self poor sense of self
Which psychiatric conditions are commonly comorbid with each type of
personality disorder?
o Cluster A schizophrenia
o Cluster B bipolar
o Cluster C anxiety

Child and Adolescent Psychiatry


Questions

What are the key principles of attachment theory? How is attachment


theory useful in the understanding of psychiatric presentations?
o Baby cries to communicate what it want mother feeds infant
o If the mother responds correctly, the baby feels understood, knows
its giving the right signals builds close relationship
o A: avoidant of negative afect and predictable
Child operates at emotional distance, emotional inhibited,
logically biased
o B: Secure and balanced (respond to childs need for security and
exploration)
Child learns to come and go with equal confidence
o C: Preoccupied with negative afect and unpredictable
Child exaggerates emotional displays to get a more
consistent return from an inconsistent carer
Describe Eriksons stages of psychosocial development
o Infancy birth to 18 months: trust vs mistrust
Baby learns who to trust learns what is safe
o Early childhood 2 to 3 years: autonomy vs shame and doubt
Child learns to do what they want, can voice wants (tantrum)
o Kindergarten 3 to 5 years: initiative vs guilt
Forming new relationships, and develops sense of self and
leadership
o School age 6 to 11 years: industry vs inferiority
Development of movement and language, success in these
areas self esteem
o Adolescence 12 to 18 years: identity vs role confusion
Finding their place in relationships and friendship groups

Describe the core domains of dysfunction in the DSM V diagnosis of


Autism spectrum disorder
o Deficits in social communication and interaction
o Restricted, repetitive patterns of behaviour, interests or activities
o Symptoms must be present in early developmental period, and
must cause clinically significant impairment in social, occupational
or other important areas of function.
Describe the core domains of dysfunction in Attention Deficit/Hyperactivity
Disorder
o Inattention at least 6 months, degree that is inconsistent with
developmental level and negatively impacts on social and academic
activities
o Hyperactivity and impulsivity as above
o Symptoms present prior to age 12 years, and present in two or
more settings
Discuss the diferential diagnosis of Attention Deficit/Hyperactivity
Disorder
o Oppositional defiant disorder resist work as they resist conforming
to others demands, characterised by negativity, hostility and
defiance
o Intermittent explosive disorder similar impulsivity, but patients
with IED show aggression towards others
o Specific learning disorder may appear inattentive because of
frustration or limited ability, but not impaired outside of academic
work

Anxiety Spectrum
Questions

In the clinical setting, how would you diferentiate between anxiety and an
anxiety disorder?
o Anxiety is the normal fight or flight response to a perceived
dangerous stimuli
o Pathological anxiety involves an inappropriate response to a given
stimulus by virtue of its intensity or duration disproportionate
response significant distress and impairment of function
Give a brief overview of the Anxiety Disorders as described in DSM-V
o Separation Anxiety Disorder
o Selective Mutism
o Panic Disorder
o Agoraphobia
o Specific Phobia
o Social Anxiety Disorder (Social Phobia)
o Generalised Anxiety Disorder
o Post-traumatic Stress Disorder (DSM IV)
o Obsessive Compulsive Disorder (DSM IV)
When would you diagnose a patient as sufering from a GAD?
o BESKIM (>3), majority of days > 6 months
What is the diferential diagnosis of GAD?

Anxiety disorder due to another medical condition (phaeo,


hyperthyroidism)
o Substance-induced anxiety disorder
o Social anxiety disorder specifically worried about upcoming social
situations where they must perform of be evaluated
When would you diagnose a patient as sufering from a Panic Disorder?
o Recurrent, unexpected panic attacks followed by at least one month
of persistent concern about having another attack
When would you diagnose a patient as sufering from OCD?
o Presence of obsession, compulsions or both
o Obsessions
Recurrent and persistent thoughts, urges or images, intrusive
and unwanted anxiety or distress
Attempts to ignore or suppress thoughts
o Compulsions
Repetitive behaviours, with rigidly-applied rules
Behaviours are aimed at reducing anxiety or distress, but are
excessive
o Symptoms cause clinically significant distress or impairment in
areas of functioning
How is OCD diferent from OCPD?
o OCD is unwanted, whereas OCPD is part of the persons personality
When would you diagnose a patient as sufering from a post-traumatic
stress disorder?
o Exposure to actual or threatened death, serious injury or sexual
violence
o Presence of intrusive symptoms (distressing memories, dreams,
flashbacks, inappropriate response to internal or external cues that
symbolise or represent event)
o Persistent avoidance of stimuli associated with traumatic event
o Negative alterations in cognitions and mood associated with
traumatic event
o Sleep or concentration disturbance
When would you diagnose a patient as sufering from a Social Phobia?
o 6 month history of symptoms, causing clinically significant distress
or impairment
o Marked fear or anxiety about social situations in which the
individual is exposed to possible scrutiny by others avoidance of
social situations
o Fear that behaviour will be negatively evaluated (embarrassment
rejection)
What is the diference between Agoraphobia and Social phobia?
o Agoraphobia may fear social situations because escape might be
difficult
o Social phobia fear of scrutiny by others, but calm when left alone
What is the diference between Social phobia and an Avoidant Personality
Disorder?
o Avoidant personality broader avoidance pattern
o Often comorbid
o

When would you diagnose a patient as sufering from a Specific Phobia?


o Symptoms last 6 months or more, cause clinically significant
distress or impairment
o Marked fear or anxiety about a specific object or situation
avoidance of phobia
o Fear is out of proportion to actual danger
What are the clinical features of a panic attack?
o Abrupt, reach peak within 10 minutes
Dizziness/lightheadedness
Sweating, trembling, shaking
Choking
SOB
Palpitations
Nausea/abdominal distress
Fear of losing control, or dying
What are the diferential diagnoses of a panic attack?
o Phaeochromocytoma
o MI
o Asthma
o Hyperthyroidism
How do you assess and manage panic attacks?
o Breathing slowly, or rebreathing into a hand-held bag placed over
mouth increased arterial carbon dioxide concentration

Walkthrough
1. Diferentials
a. Panic disorder
b. Generalised anxiety disorder
c. Organic disease cardiac arrhythmias, ischaemic heart disease,
phaeochromocytoma
d. Substance-induced
2. Assess medical stability
3. Risk assessment
a. GAD and panic disorder patients often have depression, screen for
suicide
b. Aggression or suicidal ideation if alcohol/drug abuse, RFs as well as
comorbidities
4. Collateral history
5. History
a. Panic disorder (abrupt + reach peak within 10 minutes)
i. Dizziness/lightheadedness
ii. Sweating, trembling, shaking
iii. Choking
iv. SOB
v. Palpitations
vi. Nausea/abdominal distress
vii. Fear of losing control, or dying
b. Agoraphobia
i. Anxiety about being in places or situations where escape
might be difficult or embarrassing

c. Generalised anxiety disorder (anxiety/worry on majority of days > 6


months)
i. Blank mind
ii. Easily fatigued
iii. Sleep disturbance
iv. Keyed up (feeling on edge)
v. Irritability
vi. Muscle tension
d. Past psychiatric history
i. Previous diagnoses
ii. Prescribed medications efectiveness, compliance, side
efects
iii. Previous admissions
e. Past medical history
i. Risk factors for CVD
f. Family history
i. GAD
ii. Panic disorder/agoraphobia
g. Drug and alcohol
i. Cocaine, nicotine or cannabis predispose to panic disorder
and GAD
ii. Alcohol or drug withdrawal panic attacks or GAD
h. Developmental
i. Early separation from parent, physical or sexual abuse
ii. Stressful events
6. MSE
a. B: anxious, fidgety
b. Findings of depression
i. Depressed mood, limited range of afect
ii. Decreased rate of speech, delusions of poverty/nihilism
7. Investigations
a. ECG cardiac arrhythmias, ischaemia
b. Urine drug screen substance abuse
8. Management
a. De-escalation techniques, attempt to calm patients down if agitated
b. Panic disorder
i. Psychotherapy
1. Slow breathing strategies
2. Cognitive behaviour therapy (exposure to symptoms +
coping strategies)
ii. Pharmacotherapy
1. Oral SSRI (e.g. sertraline)
c. GAD
i. Psychotherapy
1. Education on relaxation and stress management
(problem-focused counselling, modifying lifestyle
factors)
2. CBT activity scheduling, modifying dysfunctional
thoughts
ii. Pharmacotherapy
1. Oral SSRI (e.g. sertraline)
d. General
i. Education on rationale for treatment

ii. Involvement of family


iii. Self-help groups and websites

Eating and Somatoform Disorders Spectrum


Questions

Give a brief overview of the eating disorders as described in DSM-V


o Anorexia Nervosa
Refusal to maintain body weight at or above minimally
normal
Intense fear of gaining weight or becoming fat, even though
underweight
Disturbance in perception of own body weight/shape
o Bulimia Nervosa
Purging type
Non-purging type
o Eating disorders not specified
Binge eating disorder
o Obesity
Discuss the subtypes of Anorexia Nervosa and diferences in their clinical
implications
How would you distinguish between the binging and purging type of
Anorexia Nervosa and Bulimia Nervosa?
o Very similar, but bulimics maintain body weight at or above a
minimally normal level

What
o
o
o
o
What
o
o
o
What
o
o

are the physical complications of Anorexia Nervosa?


Hypovolaemia pre-renal failure
Amenorrhoea
Grand mal seizure (electrolyte disturbance)
Arrhythmias
are the physical complications of Bulimia Nervosa?
Arrhythmias (decreased K+)
Muscle wasting
Renal failure (electrolyte disturbances)
are the risk factors associated with Eating Disorders?
Developmental anxiety disorders or obsessional traits
Environmental occupations such as elite athlete, models or
dancers, childhood abuse
o Genetics first degree relatives, high concordance with MZ twins,
childhood obesity
What do you understand by the term Somatic Symptom and Related
Disorders as discussed in DSM-V? List and describe the specific disorders
included in this category according to DSM-V
o Physical signs and symptoms lacking a known medical basis
clinically significant distress or impairment (CSDI)
o Somatisation disorders multiple organ system involvement
o Conversion disorders neurological complains
o Hypochondriasis worried about being sick with a particular illness
rather than a focus on physical symptoms
o Body dysmorphic disorder dissatisfaction with a body part
o Persistent somatoform pain disorder pain is the main complaint
When would you diagnose Conversion Disorder, and how would you
explain this condition to a patient that in your opinion may have this
condition?
o Symptoms of deficit afecting voluntary motor or sensory function
CSDI
o Preceded by conflicts or other stressors
o Not intentionally produced or feigned, cannot be explained
medically
o Emphasise their symptoms are not imaginary
What is the recognised approach to managing Conversion Disorder?
o Establish rapport
o Insight-orientated supportive or behaviour therapy
o Hypnosis, anxiolytics and behavioural relaxation exercises
In the clinical setting, how would you distinguish between a diagnosis of
Body Dysmorphic Disorder and Delusional Disorder with somatic features?
o BDD involves prominent appearance pre-occupations and related
repetitive behaviours

Walkthrough
1. Medical stability
a. Dehydration (BP, HR, sunken orbits)
b. Electrolytes (concerned about hypokalaemia ECG)
2. Setting up the interview

a. Acknowledge reluctance to talk about problem


b. Ask if they want parent present
c. Quiet room + lighting
3. Risk assessment
a. Depression suicidal
b. Drug dependence aggressive behaviour
4. Safety concerns
a. Checked for instruments of self-harm (e.g. razor blades)
5. Collateral
a. Nursing staf
b. Parents/caregivers
c. Case notes
6. History
a. Eating binges feelings of self-disgust
b. Unhealthy attempts at weight loss vomiting, use of laxatives
c. Combination of restricted diet + excessive exercise
d. Inadequate nutrition fatigue
e. Complications
i. Depression
ii. Mallory Weiss tear haematemesis
iii. Amenorrhoea in post-menarchal female (decreased body fat
hormonal imabalance)
f. Family history
i. Alcoholism, depression, eating disorder
g. Drug and alcohol history
i. Polysubstance or alcohol abuse (further risk of poor nutrition)
h. Developmental history
i. History of body image dissatisfaction
ii. History of sexual abuse
iii. Elite athlete/dancer
iv. Cluster B personality disorder traits
7. MSE
a. Appearance
i. Average or above-average weight (due to binges)
b. Insight and judgment
i. Poor
8. Management
a. Uncomplicated bulimia can usually be treated out of hospital,
whereas patients with concurrent depression or substance abuse
should be admitted
b. Multidisciplinary approach, consisting of health professional,
nutritionist and family members, trust is important
c. Identify stressors
d. Acknowledge patients feelings and help develop coping strategies
9. Nutritional rehabilitation
a. Education encourages healthy eating and lifestyle
10.Psychotherapy
a. CBT as efective as medication
11.Medication
a. SSRI safest antidepressants to use in bulimia nervosa
i. Especially useful with depression, anxiety and to those who
havent responded to psychosocial therapy
ii. Especially useful in reduction of binge eating

iii. Use in combination with psychotherapy higher remission

Class
Name
SSRI
Sertraline

Dose
Route
50100mg
mane
Oral

Mechanism

Side Effects

Inhibit reuptake of serotonin


into presynaptic cell
Increased serotonin in
chemical synapse
Serotonin can continue to bind
to post-synaptic cell
Increased neurotransmission
Blocks dopamine D2 receptors
in brain decreased efect of
dopamine

Diarrhoea;
Nausea;
Headache;
Insomnia;

Typical antipsychotic
Haloperidol

1.510mg nocte
Oral

Atypical
antipsychotic
Olanzapine
Lithium

510mg nocte
Oral

Anticonvulsant
Sodium valproate

200-400mg BD
Oral

Blocks sodium channels


Reduces neuronal activity and
stabilises membranes

Benzodiazepine
Diazepam

5-1040mg
daily

Promotes efects of GABA


presynaptic inhibition

Blocks dopamine type 1 and 2


receptors and serotonin type 2
(5-HT2) receptors

750-1000mg
nocte
Oral

Akathisia;
Sedation;
Weight gain;
Parkinsonism;
Hyperglycaemia;
Weight gain;
Peripheral oedema;
Leukocytosis;
Tremor;
Confusion;
Nausea/vomiting;
Nausea;
Weight gain;
Hair loss;
Lethargy;
Drowsiness;
Light-headedness;

Oral

sedation

Memory loss;
Slurred speech;