Guidelines for the Pharmacotherapy of Major Depressive Disorder I have summarised the following recommendations from the Maudsley prescribing guidelines in Psychiatry, 13th Ed. Psychotherapies Supportive psychotherapy, CBT, interpersonal therapy, marital/couple therapy, dynamic psychotherapy, behavioral activation Depressive episode Step-1 SRI/ Mirtazapine à A generic SRI; use mirtazapine if sleep needed Step-2 SSRI/non-SRI   à Most evidence is for a switch to vortioxetine Step 3 Mirtazapine, vortioxetine, agomelatine   à if not already trialed

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Because of its N-methyl-d-aspartic acid antagonist properties, amantadine (100–500   mg three times a day), and its derivative memantine (5–20   mg/day), have been tried in catatonia. Carroll and coworkers identified 25 cases of amantadine and memantine use in the treatment of catatonia. All cases improved, mostly after 1–7   days. It should be noted, however, that six were unpublished, and that seven other were cases experiencing a “catatonia-parkinsonian syndrome” while under treatment with the high-potency neuroleptic drugs haloperidol or fluphenazine. The symptoms diminished when neuroleptics were tapered, and they added amantadine. Since then, they have published eleven additional cases describing the successful use of amantadine or memantine in catatonia. In one case, in an adolescent girl, catatonia that was resistant to ECT improved after the addition of amantadine. Only in a review of Hawkins and coworkers, they report a case in which the use of amantadine remained without eff

Stuttering and Stammering We may also call stammering. In the Diagnostic and statistical manual fifth edition, they call it Childhood-onset fluency disorder: Repetitions or prolongations of speech sounds OR Hesitations/pauses Marked disturbance in the fluency of speech.  Frequently associated movements, for example: Eye blinks  Tics Tremors of the lips or face Jerking of the head Breathing movements Fist-clenching These coincide with the stutters.  Tip > both Stuttering and Stammering include S as in heSitations Compare this to Staccato Speech

Difficulty tolerating anger. Physical or emotional separation from a significant person both in childhood and in adult life  Situations of increased work responsibilities may trigger it  Perception of parents as controlling, shocking, cynical, and demanding  Internal representations of relationships involving sexual or physical abuse  A chronic sense of feeling trapped  A vicious cycle of anger at parental rejecting behavior followed by anxiety that the fantasy will destroy the tie to parents. Failure of signal anxiety function in ego related to self fragmentation and self-other boundary confusion 

  Evaluation, Differential Diagnosis, and Treatment Evaluation Effective treatment starts with a swift and correct diagnosis. In any patient exhibiting marked deterioration in psychomotor function and overall responsiveness, we should consider catatonia. Any patient that is admitted to a psychiatric ward with a severe psychiatric disorder, such as depression, bipolar disorder, a psychotic disorder, or autism spectrum disorder, should be examined routinely. Some signs and symptoms are clear upon observation of the patient during a psychiatric interview. Other specific symptoms, however, such as automatic obedience, ambitendency, negativism should be elicited during a neuropsychiatric examination. Scales We can use a rating scale as a screening instrument and aid in the detection and quantification of catatonia. We have found several rating scales reliable, sensitive, and specific: Rogers Catatonia Scale Bush-Francis Catatonia Rating Scale Northoff Catatonia Rating Scale Braunig Catatoni

An overview of Catatonia Catatonia is a severe motor syndrome with an estimated prevalence among psychiatric inpatients of about 10%. Catatonia can accompany many psychiatric illnesses and somatic diseases. A minority of catatonic patients suffer from schizophrenia, while a majority has a bipolar disorder. They have also linked catatonia to other psychiatric disorders, such as obsessive-compulsive disorder, post-traumatic stress disorder, or withdrawal from alcohol or benzodiazepines. In up to 25% of cases, they relate catatonia with general medical or neurologic conditions. Recent studies show repeatedly that catatonic symptoms are observable in most patients diagnosed with anti-N-methyl-d-aspartate receptor encephalitis. In adolescents and young adults with autism, we find catatonia in 12–17%. Pediatric catatonia also emerges in patients with tic disorders, and a variety of other (developmental) disorders. The same principles of evaluation and treatment seem to apply to pediatric pat

Disulfiramlike Reaction Disulfiram irreversibly inhibits aldehyde dehydrogenase, by competing with nicotinamide adenine dinucleotide at the cysteine residue. Aldehyde dehydrogenase is a hepatic enzyme of alcohol metabolism converting ethanol to acetaldehyde. At therapeutic doses of disulfiram, alcohol consumption causes elevated serum acetaldehyde, causing manifestations given below. Manifestations • Diaphoresis • Facial flushing • Hypotension • Nausea • Palpitations • Tachycardia • Vertigo We call this constellation of symptoms the disulfiram-alcohol reaction; it discourages alcohol intake. The severity of the reaction is proportional to the dose of disulfiram, and that of alcohol. It is NOT an anti-craving drug and DOES NOT affect the neurobiology of addiction. NICE guidelines on the Use of Disulfiram Disulfiram should be considered in combination with a psychological intervention for patients who wish to achieve abstinence, but for whom acamprosate or naltrexone is not

CATIE  Clinical Antipsychotic Trials of Intervention Effectiveness A Multicenter, double-blind, parallel-group, randomized, controlled trial

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MRCPsych Paper B SAMPLE SIZE CALCULATION Critical Review Question You are checking the frequency of “the Perceived stress scale among doctors serving at various Government and private hospitals in Faisalabad. (JPMA-2020-02-232)” If you aimed for a specific category of doctors, then that will be your target population. For example juniors, seniors, permanent visiting, etc. Introduction Once we plan a survey or a research experiment, then we have a target population in mind. For example, some surveys cover the entire population of the country like census and political elections. If we take an example for census first, then what sample size do you think would be the correct representative in that case? The obvious answer is 100% of the population of the country, not a single percent less. Examples Now take the example of the political elections, let’s say 50% was the turnout on polls. Would that be an excellent election turn out? Probably not, because half the population of the country d

  Sampling Stratified & Random  Stratified Sampling Random sampling refers to sampling via which every member of the target population has an equal chance of making it to the sample. Assign numbers and choose random, place names in a box and select.  Random Sampling Stratified sampling is when the demographic characteristics of the target population are reflected in the sample. For example, if there are 1% working females in a target population, then the sample should also have 1% working females. 

Can you appear in MRCPsych Paper B with 12 months' of an experience only? Can someone appear in MRCPsych paper B if she has done just MO-ship ( non-trainee) in a private sector for 12 months in psychiatry, especially if her supervisor is a Consultant registered with the Royal College of Psychiatrists? Yes, you can as far as I understand, but you need to submit the confirmation of the following as stated on the RCPsych website : Eligibility criteria for Paper B You are in an approved training program. They recommend you have 12 months’ experience in psychiatry before attempting Paper B. OR: You are in a post recognized by your hospital or trust as having contracted time and funding for educational training. Your job plan must include dedicated time for academic and educational activities such as attending journal clubs, grand rounds, attending an MRCPsych course of equivalent, study leave, and weekly educational supervision.

Tuberous Sclerosis Tuberous sclerosis (epiloia) has an Autosomal dominant inheritance pattern. Clinical features include Epilepsy, adenoma sebaceous on the face, white skin patches, shagreen skin, retinal phakoma, subungual fibromata, multiple renal, and other tumors. ID usually is Mild. Autism and other psychiatric disorders are common.

Neuroleptic malignant syndrome  Manifestations MNEMONIC FEVER Fever Encephalopathy Vitals Unstable Enzymes Rigidity of Muscles Treatment Dantrolene D2 agonists (e.g., bromocriptine).

Child Psychiatry MCQ for MRCPsych Paper B A 7-year-old child came with his mother to your Outpatient clinic for assessment because of ongoing difficulties for the past 1 year. The mother shared that the child is always on the go and cannot sit still. Recently, he nearly had an accident when he dashed across the traffic junction. The school report card mentions he is inattentive most of the time. What psychometric tool will you apply in this case? CY-BOCS CONNORS ADOS DISCO CDI

MRCPsych Paper B: 600 MCQs and EMIs MRCPsych examination has changed from Paper 1,2,3 to Paper A and B and the first-ever sitting of the `Paper B' examination was on 14th April 2015.  MRCPsych Paper B: 600 MCQs and EMIs is the sole review book that covers the new Paper B examination syllabus.  This book comprises 3 full test papers; 2 matching the syllabus to help with revision and one unstructured to provide authentic mock examination paper practice.  MRCPsych Paper B: 600 MCQs and EMIs offer the most up-to-date and comprehensive collection of practice questions for trainees preparing for the new MRCPsych Paper B. they have plotted the questions  plotted per the syllabus to present organised revisions on all the key topics, allowing readers to focus on areas of weakness.  Featuring a wealth of practice questions and answers, this book is an essential revision tool to maximise the chances of examination success. Key Points 600 MCQs and EMIs reflect the breadth of topics encountered

Extended matching items   What are the extended matching questions and how many can you expect in the MRCPsych Exam? An extended-matching items/question  ( EMI  or  EMQ ) is a written examination format similar to multiple-choice questions but with one key difference, that they test knowledge in a far more applied, in-depth, sense. We often use it in medical education and other healthcare subject areas to test diagnostic reasoning. Structure The structure has three key elements: Answer option list Sources suggest using a minimum of eight answer options for a  ratio  of five  scenarios  or  vignettes  to ensure that the probability of getting the correct answer by chance remains reasonably low. [1]  The logical number of realistic options should dictate the exact number of answer options. The logical number of realistic options should dictate the exact number of answer options. This ensures that the test item has authenticity and  validity . Lead-in question: This should be as specific

Preparing for MRCPsych Paper B with Parsa Amin I passed paper B using an online exam in October and thought I’d just share what I did while it’s still fresh in my brain so it can help a few. I had an extremely comfortable pass & this is what I did. 1. SPMM Qbank - as I meant to do this exam in March 2020 (Thanks COVID19)- I ended up doing the Qbank average 4 - 5 times. (I didn’t study between March 2020-May2020). I technically did 4 months before this exam knowledge from previous revision pre-March 2020. I used google/ NICE guidelines to read up on only topics I didn’t understand. Focus on EMI’s on SPMM the month before the exam - if you are scoring well, it shows you know your stuff. SPMM 13 timed mocks (they updated it to simulate a real exam, worth the price) - did only once- timed like in the exam situation, I sat them using the area I sat the actual exam. Cambridge Critical Appraisal course - I also did it twice as I was meant to take an exam in March. SPMM statistics videos -

Cambridge stats course. It runs online over a weekend and is excellent. SPMM MRCPSych Mentor