{"title": "Chapter 15: Psychiatric Disorders, Substance Use, and Emergency Medicine", "flashcards": [{"q": "What are the DSM-5-TR diagnostic criteria for a major depressive episode?", "a": "≥5 of 9 symptoms for ≥2 weeks, at least one being depressed mood or anhedonia: depressed mood; anhedonia (markedly diminished interest/pleasure); weight/appetite change; insomnia or hypersomnia; psychomotor agitation or retardation; fatigue/loss of energy; feelings of worthlessness or excessive guilt; impaired concentration/decision-making; recurrent thoughts of death/suicidal ideation. Causes clinically significant distress or functional impairment."}, {"q": "What is the C-SSRS (Columbia Suicide Severity Rating Scale) and its clinical application?", "a": "A standardised validated interview-based scale assessing suicidal ideation (5-item: wish to be dead → active ideation with intent and plan) and suicidal behaviour (5 types: preparatory acts, interrupted attempt, aborted attempt, actual attempt, completed suicide). Ideation intensity subscale and behaviour subscale provide dimensional measurement. Widely used in EDs, psychiatric settings, and clinical trials to communicate risk consistently."}, {"q": "Name the four components of the Mental Capacity Act 2005 (England and Wales) assessment.", "a": "A person lacks capacity if they are unable to: (1) Understand relevant information about the decision; (2) Retain that information long enough to make a decision; (3) Use or weigh the information; (4) Communicate their decision (by any means). Assessment is decision-specific and time-specific. Presumption of capacity unless proven otherwise. Best-interests decision-making if capacity is lacking."}, {"q": "What is the CIWA-Ar score used for?", "a": "Clinical Institute Withdrawal Assessment for Alcohol (Revised) measures severity of alcohol withdrawal: 10 domains (nausea/vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile/auditory/visual disturbances, headache, orientation). Score ≥10 indicates moderate withdrawal; ≥15 = severe; ≥20 = risk of seizures/delirium tremens. Guides chlordiazepoxide/diazepam dosing in alcohol withdrawal management."}, {"q": "What is the pharmacological management of opioid use disorder (OUD)?", "a": "Opioid substitution therapy (OST): buprenorphine-naloxone (Suboxone — first-line, sublingual; partial mu-agonist + antagonist blocks injection misuse) or methadone (full mu-agonist, daily supervised consumption). Both reduce illicit opioid use, overdose mortality, criminal behaviour, and blood-borne virus transmission. Naltrexone (extended-release injectable) is an opioid antagonist for relapse prevention after detoxification."}, {"q": "Name the key features that distinguish bipolar I from bipolar II disorder.", "a": "Bipolar I: at least one full manic episode (≥7 days, or any duration if hospitalisation required; elevated/irritable mood + 3+ features from DIGFAST — Distractibility, Impulsivity, Grandiosity, Flight of ideas, Activity, Sleep decreased, Talkativeness). Bipolar II: hypomanic episodes (≥4 days, less severe, no hospitalisation, no psychosis) + at least one major depressive episode. Psychosis occurs only in Bipolar I (and sometimes MDD with psychotic features)."}, {"q": "What is the mechanism of action of SSRIs and name two adverse effects.", "a": "SSRIs (fluoxetine, sertraline, escitalopram, citalopram, paroxetine) selectively inhibit the serotonin reuptake transporter (SERT) in presynaptic neurones, increasing synaptic serotonin concentration. Adverse effects: sexual dysfunction (most common long-term complaint — ~40%); GI upset (nausea, diarrhoea — usually transient); insomnia or somnolence; weight gain (long-term); discontinuation syndrome (especially paroxetine — short half-life); SIADH; serotonin syndrome with co-administered serotonergic drugs."}, {"q": "What are the four ABCDE steps of advanced life support (ALS)?", "a": "ALS algorithm for non-shockable rhythms (PEA/asystole): 1) Initiate high-quality CPR (30:2; continuous chest compressions 100–120/min once airway secured); 2) IV/IO access + adrenaline 1 mg IV every 3–5 min; 3) Reversible causes (4Hs/4Ts); 4) Defibrillation immediately for shockable rhythms (VF/pVT) — 1 shock then resume CPR for 2 min without rhythm check. Do not interrupt CPR for rhythm checks in PEA/asystole."}, {"q": "What is the ISBAR communication framework in emergency handover?", "a": "ISBAR: Identify (yourself, patient, location); Situation (what is happening, why calling); Background (relevant history, medications, investigations); Assessment (current clinical status, diagnosis or differential); Recommendation/Request (what you need — investigation, review, transfer, escalation). ISBAR structures urgent clinical communication, reduces information loss, and supports patient safety in handover and escalation."}, {"q": "Name three antidotes and their specific indications.", "a": "N-acetylcysteine (NAC) — paracetamol overdose (replenishes glutathione, detoxifies NAPQI); naloxone — opioid toxicity (competitive mu-receptor antagonist, short-acting; may need repeat dosing); flumazenil — benzodiazepine toxicity (use with caution — can precipitate seizures in benzodiazepine-dependent patients); atropine — organophosphate poisoning/bradycardia; hydroxocobalamin — cyanide poisoning; digoxin-specific Fab fragments — severe digoxin toxicity."}], "quiz": [{"q": "Which antidepressant class has the lowest risk of drug interactions and is safest in overdose?", "opts": ["Tricyclic antidepressants (TCAs)", "SSRIs (and SNRIs — e.g. sertraline, escitalopram) — lower cardiotoxicity in overdose and fewer significant drug interactions than TCAs or MAOIs", "MAOIs", "Venlafaxine"], "ans": 1, "exp": "SSRIs are first-line antidepressants due to safety in overdose (low cardiotoxicity compared to TCAs), tolerability, and efficacy. TCAs (e.g. amitriptyline) cause lethal cardiotoxicity in overdose (QT prolongation, QRS widening, ventricular arrhythmias) and anticholinergic effects. MAOIs have multiple food and drug interactions (tyramine reactions, serotonin syndrome). SNRIs are also first-line for anxiety disorders."}, {"q": "What is the 'section 2' of the Mental Health Act 1983 (England and Wales)?", "opts": ["Voluntary informal admission", "Compulsory admission for assessment for up to 28 days — requires two medical recommendations (one Section 12 approved doctor) and an approved mental health professional (AMHP); must be discharged, transferred to Section 3, or become informal by day 28", "Emergency detention for 72 hours", "Treatment order for 6 months"], "ans": 1, "exp": "MHA Section 2: compulsory admission for assessment (±treatment) for up to 28 days. Criteria: the person has (or is suspected of having) a mental disorder warranting detention for their own health/safety or protection of others; they must be admitted for assessment (±treatment). Requires AMHP application + two medical recommendations. Section 3: treatment order up to 6 months. Section 4: emergency admission by one doctor for 72 hours."}, {"q": "What is the first-line pharmacological treatment for acute mania in bipolar disorder?", "opts": ["Antidepressant alone", "Atypical antipsychotic (e.g. olanzapine, quetiapine, risperidone, aripiprazole) ± short-term benzodiazepine for agitation; lithium or valproate for maintenance mood stabilisation", "SSRI alone", "Carbamazepine alone"], "ans": 1, "exp": "NICE NG185 (2023): for acute mania, start or optimise an antipsychotic (olanzapine, quetiapine, risperidone, or haloperidol). Avoid antidepressants (can trigger/prolong mania). Lithium can be added or used as an alternative. Valproate is preferred in men (teratogenic in women of childbearing potential). Benzodiazepines provide short-term sedation for severe agitation."}, {"q": "What is the FAST alcohol screening tool?", "opts": ["Five-item questionnaire about heavy drinking patterns", "3 questions about frequency of heavy drinking + 1 question about failed obligations (abbreviated AUDIT); score ≥3 in men and ≥2 in women indicates hazardous/harmful drinking", "A 10-item questionnaire identical to AUDIT", "A blood test for alcohol markers"], "ans": 1, "exp": "FAST (Fast Alcohol Screening Test) is a 4-item questionnaire derived from AUDIT. Questions: how often ≥6 units in one occasion; how often someone concerned about drinking; how often unable to remember; how often failed obligation due to drinking. Score ≥3 in men (≥2 in women) suggests hazardous/harmful use. Used in primary care and ED settings for rapid alcohol screening."}, {"q": "Which medication is used for alcohol relapse prevention in patients who have completed detoxification?", "opts": ["Chlordiazepoxide", "Acamprosate (or naltrexone/disulfiram) — reduces craving and helps maintain abstinence after successful detoxification", "Diazepam", "Thiamine alone"], "ans": 1, "exp": "Relapse prevention after alcohol detoxification: acamprosate (calcium acetylhomotaurinate) — modulates glutamate/GABA neurotransmission, reducing craving; must be abstinent before starting. Naltrexone — opioid antagonist, reduces reward from alcohol. Disulfiram — blocks acetaldehyde dehydrogenase, causing aversive reaction to alcohol (flushing, nausea, palpitations); requires daily supervision. All used alongside psychosocial support."}, {"q": "What is neuroleptic malignant syndrome (NMS) and how is it treated?", "opts": ["A side effect of SSRIs causing anxiety", "Life-threatening reaction to antipsychotics characterised by hyperthermia, lead-pipe rigidity, altered consciousness, and autonomic instability; CK >1000 IU/L; treated by stopping antipsychotic, IV dantrolene, bromocriptine, supportive ICU care", "An extrapyramidal reaction treated with procyclidine", "Serotonin syndrome identical to NMS"], "ans": 1, "exp": "NMS: tetrad of hyperthermia, rigidity (lead-pipe, not cogwheel), altered level of consciousness, and autonomic instability (diaphoresis, labile BP, tachycardia). CK markedly elevated; leukocytosis; AKI from rhabdomyolysis. Onset: hours-days after starting or increasing antipsychotic dose. Management: stop antipsychotic; IV dantrolene (muscle relaxant); bromocriptine (dopamine agonist); aggressive supportive care including cooling, hydration, ITU."}, {"q": "What is serotonin syndrome and which drug combination most commonly causes it?", "opts": ["Any SSRI in high dose alone", "Combination of serotonergic drugs (e.g. SSRI + MAOI; SSRI + tramadol; SSRI + linezolid; SSRI + triptans) causing excess serotonergic activity — presenting with agitation, clonus, tremor, hyperthermia, and autonomic instability", "Antipsychotic + anticholinergic", "Benzodiazepine + opioid combination"], "ans": 1, "exp": "Serotonin syndrome: caused by excess serotonergic activity from drug combinations. Hunter criteria: clonus (spontaneous, inducible, ocular) is the most sensitive finding; agitation, hyperreflexia, tremor, diaphoresis, mydriasis, tachycardia, hyperthermia. SSRI + MAOI is the most dangerous combination (contraindicated; requires 2-week washout). Treatment: stop serotonergic drugs, cyproheptadine (5-HT2A antagonist), supportive care."}, {"q": "What is the management of acute alcohol withdrawal delirium tremens?", "opts": ["Observation only", "IV/oral benzodiazepine (chlordiazepoxide or lorazepam IV in severe cases) titrated to CIWA-Ar score + IV thiamine (Pabrinex) + fluid/electrolyte replacement + frequent monitoring in high-dependency setting", "Antipsychotics as sole treatment", "Oral thiamine tablets alone"], "ans": 1, "exp": "Delirium tremens (severe alcohol withdrawal with hallucinations, seizures, autonomic hyperactivity, confusion) typically emerges 48–72 hours after last drink. Management: high-dependency/ICU admission; IV Pabrinex (thiamine) BEFORE glucose; large doses of IV lorazepam or phenobarbital for refractory agitation/seizures; electrolyte correction (Mg, K, PO₄); anticonvulsants if seizures occur. Mortality: 5–15% untreated, <1% with appropriate management."}, {"q": "A patient is found unresponsive with pinpoint pupils and slow respirations. What is the immediate management?", "opts": ["Flumazenil IV", "Airway management + ventilatory support + naloxone 0.4 mg IV/IM (repeat every 2 min up to 10 mg); call for emergency assistance", "Glucose IV", "CT head immediately"], "ans": 1, "exp": "The triad of pinpoint pupils (miosis), reduced GCS, and respiratory depression = opioid toxicity until proved otherwise. Management: basic airway manoeuvres → supplemental oxygen → naloxone 0.4 mg IV/IM (onset 2 min, duration 30–90 min). Repeat every 2 minutes if no response. Naloxone half-life shorter than most opioids — watch for re-sedation. IV access, continuous monitoring. Consider ITU for long-acting opioid toxicity."}, {"q": "What are the six Hs and six Ts of reversible causes of cardiac arrest?", "opts": ["Hypoxia, Hypovolaemia, Hyperkalaemia, Hypothermia, Hydrogen ions; Tension pneumothorax, Tamponade, Toxins, Thrombosis (PE), Thrombosis (coronary)", "Hypoxia, Hypovolaemia, Hypo/hyperkalaemia (and other metabolic), Hypothermia; Tension pneumothorax, Cardiac Tamponade, Toxins/drugs, Thromboembolism (pulmonary or coronary)", "Haemorrhage, Hyperglycaemia; Tumour, Trauma, Thyroid storm", "Only 4 Hs and 4 Ts exist in the ALS algorithm"], "ans": 1, "exp": "The ALS 4Hs and 4Ts (restyled in some versions as more): Hypoxia; Hypovolaemia; Hypo/hyperKalaemia and metabolic causes; Hypothermia. Tension pneumothorax; cardiac Tamponade; Toxins (drugs, poisons); Thromboembolic/mechanical obstruction (pulmonary embolism, coronary thrombosis). Identifying and correcting these reversible causes is the critical parallel action alongside CPR. Some mnemonics add Hydrogen ion (acidosis) as a fifth 'H.'"}, {"q": "What is the DSMV-TR diagnostic criteria for generalised anxiety disorder (GAD)?", "opts": ["Panic attacks alone", "Excessive anxiety and worry about multiple events/activities, more days than not for ≥6 months, difficult to control, associated with ≥3 of 6 symptoms (restlessness, fatigue, concentration difficulty, irritability, muscle tension, sleep disturbance), causing significant distress or functional impairment", "Specific phobia", "Social anxiety disorder only"], "ans": 1, "exp": "GAD requires worry that is pervasive (multiple topics), chronic (≥6 months), out of proportion to the threat, difficult to control, and accompanied by somatic symptoms. First-line treatment: SSRI or SNRI (sertraline, venlafaxine, duloxetine, escitalopram) + CBT (cognitive restructuring, relaxation, behavioural activation). Benzodiazepines are not recommended for long-term treatment due to dependence risk. Buspirone is an anxiolytic alternative."}, {"q": "What is the mechanism of alcohol causing Wernicke's encephalopathy?", "opts": ["Direct neurotoxicity of ethanol", "Thiamine (vitamin B1) deficiency from poor dietary intake + impaired absorption in chronic alcohol use; thiamine is a co-factor for pyruvate dehydrogenase, alpha-ketoglutarate dehydrogenase, and transketolase — essential for glucose metabolism in the brain; deficiency causes selective haemorrhagic necrosis in the mammillary bodies, thalamus, and periaqueductal grey", "Hypomagnesaemia from alcohol diuresis", "Hypoglycaemia only"], "ans": 1, "exp": "Wernicke's encephalopathy: CLASSIC triad is confusion, ophthalmoplegia (lateral gaze palsy/nystagmus), and ataxia — but all three present together in only ~16% of cases. If untreated → Korsakoff's psychosis (anterograde amnesia, confabulation — usually irreversible). Treatment: IV Pabrinex (thiamine 500 mg TDS IV for 2–3 days) BEFORE glucose or feeds. High-dose thiamine MUST be given IV (oral not absorbed adequately in alcohol misuse)."}, {"q": "Which antipsychotic is associated with the highest risk of metabolic syndrome?", "opts": ["Haloperidol", "Clozapine (and olanzapine — both cause significant weight gain, hyperglycaemia, dyslipidaemia, insulin resistance) — metabolic monitoring is mandatory at baseline and 3-monthly for clozapine", "Aripiprazole", "Amisulpride"], "ans": 1, "exp": "Clozapine causes the most weight gain and metabolic disturbance of all antipsychotics. Monitoring: FBC weekly for 18 weeks then monthly (agranulocytosis risk — requires CPMS/CARMS registration), weight/BMI, fasting glucose/HbA1c, lipids, BP, and prolactin. Clozapine is reserved for treatment-resistant schizophrenia (failure of ≥2 antipsychotics) but achieves response in ~40–60% where others fail. Also risk: myocarditis, hypersalivation, constipation, seizures, sedation."}, {"q": "What is a 'personality disorder' and how does it differ from a psychiatric illness?", "opts": ["A personality disorder is a severe mental illness requiring hospitalisation", "An enduring pattern of inner experience and behaviour deviating markedly from cultural expectations, pervasive and inflexible, stable since adolescence, leading to significant distress or functional impairment — differs from mental illness in its ego-syntonic nature (felt as normal part of self), chronicity, and lack of episodic symptom pattern", "A deliberate behavioural choice", "Only diagnosable in adults over 30"], "ans": 1, "exp": "DSM-5-TR clusters: Cluster A (odd/eccentric — paranoid, schizoid, schizotypal); Cluster B (dramatic/emotional — antisocial, borderline, histrionic, narcissistic); Cluster C (anxious/fearful — avoidant, dependent, obsessive-compulsive). BPD (emotionally unstable PD, impulsive/borderline type in ICD-11): emotional dysregulation, identity disturbance, impulsivity, suicidality. Treatment: dialectical behaviour therapy (DBT) for BPD; schema therapy; mentalisation-based therapy."}, {"q": "What is the 'biopsychosocial model' in psychiatry?", "opts": ["A model that considers only biological causes of mental illness", "George Engel's framework recognising that mental health and illness result from interplay of biological (genetics, neurochemistry, medical illness), psychological (cognition, behaviour, attachment, trauma), and social (relationships, socioeconomic status, culture, stigma, housing) factors", "A purely psychodynamic model", "A model used only for substance use disorders"], "ans": 1, "exp": "The biopsychosocial model replaced the purely biomedical model by recognising that biological (neurochemical, genetic predisposition), psychological (cognitive distortions, attachment patterns, past trauma, coping strategies), and social (poverty, abuse, social isolation, cultural factors, adverse childhood experiences) all contribute to mental illness. Treatment plans integrating pharmacological, psychological (CBT, trauma-focused therapy), and social interventions yield better outcomes than any single modality."}, {"q": "What are the early warning signs of lithium toxicity?", "opts": ["Euphoria and hyperactivity", "Fine tremor (coarse at toxicity), polyuria/polydipsia, diarrhoea, nausea, cognitive slowing — with toxicity: coarse tremor, ataxia, drowsiness, confusion, slurred speech, seizures, cardiac arrhythmias; lithium has the narrowest therapeutic index (~0.6–1.0 mmol/L); precipitants: NSAIDs, ACEi/ARB, thiazides, dehydration, low-salt diet", "Tachycardia as the primary sign", "Only renal symptoms"], "ans": 1, "exp": "Lithium toxicity signs: early (1.5–2 mmol/L) — coarse tremor, vomiting, diarrhoea, drowsiness, confusion; severe (>2 mmol/L) — cardiac arrhythmias, seizures, coma, irreversible neurological damage. Manage: stop lithium, aggressive IV hydration (increases renal clearance), haemo dialysis for levels >2.5 mmol/L or severe toxicity. Drug interactions: NSAIDs reduce renal lithium clearance; ACEi/ARB and thiazides increase tubular reabsorption of lithium. 3-monthly TFT/U&E/lithium levels during stable maintenance."}, {"q": "What is motivational interviewing (MI) and in which clinical contexts is it used?", "opts": ["A confrontational counselling approach", "A person-centred, goal-directed counselling approach (Miller and Rollnick) that explores ambivalence about change and enhances intrinsic motivation using OARS principles (Open questions, Affirmation, Reflective listening, Summarising) — used in: substance use disorders, smoking cessation, weight management, medication adherence, chronic disease management", "A cognitive behavioural technique", "A psychodynamic therapy"], "ans": 1, "exp": "MI is based on the transtheoretical model and works WITH ambivalence rather than arguing against it. The 'righting reflex' — arguing for change — is specifically avoided as it increases resistance. MI increases readiness-to-change across many behaviours. Evidence supports its efficacy in alcohol/drug use reduction, smoking cessation, dietary change, physical activity, and adherence to treatment in chronic conditions. Adaptable to brief (5–10 min) or extended sessions."}, {"q": "What is cognitive behavioural therapy (CBT) and what is its mechanism in depression?", "opts": ["A long-term psychoanalytic treatment", "CBT identifies and challenges negative automatic thoughts (cognitive distortions) and maladaptive behavioural patterns (avoidance, withdrawal) that maintain depression; behavioural activation (re-engaging in rewarding activities) and cognitive restructuring (challenging catastrophic thinking) together reduce depressive symptoms; equally effective as antidepressants for mild-moderate depression", "A medication-based treatment", "A supportive counselling approach only"], "ans": 1, "exp": "CBT is based on Beck's cognitive model: negative automatic thoughts (NATs) → emotional distress → avoidance/withdrawal → reinforcing depression in a self-perpetuating cycle. CBT breaks this cycle by: (1) Cognitive restructuring — identifying and challenging cognitive distortions (catastrophising, all-or-nothing thinking, personalisation); (2) Behavioural activation — scheduling rewarding activities despite low mood. Evidence: NICE recommends CBT (and IPT) as first-line psychological therapy for depression."}, {"q": "What is delirium and how is it distinguished from dementia?", "opts": ["Delirium and dementia are identical", "Delirium: acute (hours-days), fluctuating, often reversible confusional state with reduced attention/awareness, commonly caused by acute medical illness — distinguished from dementia (chronic, progressive, stable consciousness in early stages, no acute precipitant) by its acute onset, fluctuating course, and identifiable precipitant", "Delirium is always a psychiatric diagnosis", "Dementia causes acute confusion; delirium is chronic"], "ans": 1, "exp": "Key distinctions: Delirium — acute onset (hours/days), fluctuating, inattention is the cardinal feature, disturbed sleep-wake cycle, may have hallucinations (visual most common), reversible when underlying cause treated. Dementia — insidious onset over months-years, progressive, consciousness preserved until late, no acute precipitant. Delirium can be superimposed on dementia (most common in elderly hospitalised patients — increases mortality 3-fold). 4AT score screens for delirium."}, {"q": "What is the pharmacological management of attention deficit hyperactivity disorder (ADHD) in adults?", "opts": ["Antipsychotics as first-line", "Methylphenidate (immediate-release or extended-release) or lisdexamfetamine (prodrug of dexamfetamine) as first-line stimulants; atomoxetine (selective NRI) or guanfacine as non-stimulant alternatives for those with stimulant contraindications or substance misuse risk; monitored via CQAIMH guidelines in the UK", "Benzodiazepines for hyperactivity", "SSRIs as first-line for ADHD"], "ans": 1, "exp": "NICE NG87 (2019): methylphenidate first-line for children and adults; lisdexamfetamine as second-line if methylphenidate fails or is contraindicated. Atomoxetine (SNRI mechanism — selective NE reuptake inhibitor) and guanfacine (alpha-2A agonist) are non-stimulant alternatives. Monitor: baseline and monthly BP/HR/weight/height (children); titrate to lowest effective dose; consider drug holidays for children. Combined pharmacological + CBT/coaching approach preferred for adults."}]}