2. Psych [2]

Question 1

Describe 4 clinical features that PTSD may present with.

Answer 1

Hyperarousal; hypervigilance, sleep problems, irritability, difficulty concentrating, exaggerated startle response

Avoidance, of people and place related to event

Re-experience e.g. flashbacks, nightmares, intrusive memories

Emotional numbing

Question 2

Complex PTSD is defined as PTSD but has 3 additional groups of symptoms. What are these?

Answer 2

Negative / unstable sense of self / self concept

Dysregulation of affect

Disturbance in relationships

Question 3

What are the options for treatment of PTSD?

Answer 3

In mild cases, watching and waiting can be useful, with advice about sleep hygiene etc, and regular follow ups.

CBT

EMDR (eye movement desensitization and reprocessing); patient is asked to think about the trauma whilst attending to other sensory stimulus e.g. flashing lights

SSRI or venlafaxine can also be used

Severe / refractory; may be able to add in antipsychotic e.g. risperidone if severe hyperarousal / psychotic features and no response to other treatments.

Question 4

Risk factors for PTSD can be split into person-factors and event factors. Give some of each.

Answer 4

Person:
Hx of previous trauma
Hx of previous mental health diagnosis
Lower socioeconomic status
Female
Younger age
Certain professions
Multiple other major stressors at time of event
Low social support
Refugees and asylum seekers

Event:
Increased severity of event
Longer duration of event/s e.g. years of child abuse or torture
Intentional > accidental
Physical injury included in traumatic event

Question 5

What is the prognosis of PTSD?

Answer 5

50% self resolve in 3 months.

1/3 have moderate / severe symptoms lasting for years.

Can present straight after the event, but 15% may present years later.

Patients with PTSD are more likely to have other medical problems e.g. drug and alcohol abuse, GI symptoms, cardiorespiratory symptoms etc.

Question 6

ASD involves impaired social interaction, social communication and behaviours. Give some clinical examples of how each of these areas may present in an individual with ASD.

Answer 6

Communication:
Delay / regression in language development.
Repetitive use of words or phrases.
Lack of eye contact / non-verbal communication.
Difficulty with imaginative play etc.

Interaction:
Cannot understand non-verbal social cues.
Avoids physical contact.
Doesn’t make eye contact.
Difficulty making friendships.

Behaviours:
Interest in objects / patterns / numbers over people.
Rigid routine and repetitive behaviours and anxiety and distress when this is disrupted.
Stimming / self stimulating e.g. hand flapping, rocking
Deep, intense interests.
Restricted food habits.

Question 7

ASD is a highly heritable condition, with a heritability of around 80%. Substantial proportion of this risk arises from sporadic mutations, and the same genetic variants can increase risk of neurodevelopmental disorders. What other conditions are linked to the genes that have been linked to ASD?

Answer 7

Intellectual disability
Epilepsy
ADHD
Schizophrenia

Question 8

3 areas that ASD affects:

Answer 8

Social communication

Social interaction

Behaviour

Question 9

Describe briefly the heritability and risk factors for ADHD.

Answer 9

Highest heritability of all psychiatric disorders, ~80%.

First degree relative of someone with ADHD has 20% chance of having it also.

Prenatal, perinatal and postnatal environmental factors also increase risk: maternal smoking, alcohol and heroin use during pregnancy, very low birth weight, fetal hypoxia, perinatal birth injury, prolonged emotional neglect during infancy.

Question 10

ADHD symptoms can be split into 2 groups, and individuals may display mainly one or the other, or both. What are the two groups and give examples.

Answer 10

Hyperactivity / Impulsivity:
Can’t sit still, fidgets, restless.
Talks excessively.
Difficulty taking turns.
Poor risk perception, reckless.

Inattention:
Difficulty focusing on tasks especially those that are mundane, doesn’t finish tasks, careless mistakes etc.

Easily distracted, seems like isn’t listening, frequently ‘daydreaming’.

Difficulty with organisation, e.g. day to day tasks, forgetful.

Question 11

Give some differentials for attention deficit in adults.

Answer 11

ADHD
Secondary to substance use
Intellectual disability
Secondary to other psychiatric disorder e.g. schizophrenia, depression
Brain injury
Neurodegeneration e.g. depression

Question 12

First line management of ADHD is always environmental modification and parenting skill support. Give some examples of these.

Answer 12

School age: seating plan arrangements, support of a teaching assistant.

Use of headphones to reduce distractions.

Regular movement breaks during tasks.

Reinforcing verbal instructions in writing.

Question 13

If despite optimal environmental modifications the child is still experiencing significant impairment, medication can be offered. Outline the medication options and the order of which they may be tried.

Answer 13

Methylphenidate; CNS stimulant. Comes in short acting form of Ritalin and other modified release forms e.g. Concerta XL, Xaggitin XL etc. FIRST LINE IN CHILDREN.

Lisdexamfetamine 2nd line if 6 week trial of methyphenidate at adequate dose not working / side effects.

Atomoxetine and Guanfacine = 3rd line.

Question 14

Describe when a diagnosis of ADHD should be considered.

Answer 14

At least 6 (5 in adults) symptoms of hyperactivity/impulsivity or inattention symptoms are present.
Present for >6 months and interfering with educational or occupational performance.
Symptoms started before age 12.
Present in 2 settings or more.
Cannot be explained by another disorder.

Question 15

Name 3 drugs used to treat ADHD.

Answer 15

Methylphenidate
Lisdexamfetamine
Atomoxetine
Guanfacine

Question 16

Describe the mechanism of lisdexamfetamine and prescribing notes.

Answer 16

It’s a pro-drug that is metabolised to dexamfetamine by an enzyme in red blood cells. This limits the rate at which dexamfetamine is generated, limiting its potential for abuse.

However, some patients benefit from the faster on-off times that dexamfetamine straight provides. Can try this as a second option after trial of lisdexamfetamine.

Question 17

What associations with methylphenidate might a parent come to you with concerns about, and how is this monitored?

Answer 17

Growth suppression with prolonged use.

Regular weight and height monitoring is always indicated, every 6 months, and drug holidays can be used to allow for catch-up growth.

Question 18

What is the MOA of methylphenidate? And give some side effects.

Answer 18

CNS stimulant; primarily acts as a dopamine and noradrenaline reuptake inhibitor.

Growth suppression, abdo pain, nausea, dyspepsia.

Stimulants are sympathomimetic, and can potentially suppress appetite.

Question 19

What investigation must be done prior to starting ADHD medication and why?

Answer 19

Baseline ECG, as all of these drugs are potentially cardiotoxic.

Question 20

What is recommended as first line treatment for bulimia nervosa, and what does it involve?

Answer 20

BN-GSH; bulimia nervosa guided self help.
Helps to:
Understand their eating disorder
Develop coping strategies for binge-purge cycles
Develop healthier attitudes towards food and body image
Monitor their own symptoms

Question 21

When should CBT be considered for bulimia nervosa?

Answer 21

If BN-GSH has been trialled for 4 weeks with no improvement.

Question 22

Bulimia nervosa is an eating disorder characterised by:

Answer 22

Binge eating episodes followed by purgative behaviours including intentional vomiting, use of laxative / diuretics and excessive exercise.

Question 23

Describe the DSM-5’s diagnostic criteria for bulimia nervosa (6 bullet points).

Answer 23

Recurrent episodes of binge eating.

Lack of control during episodes.

Recurrent inappropriate compensatory mechanisms to prevent weight gain.

Episodes occur at least once a week for 3 months.

Self evaluation is unduly influenced by body shape.

Does not occur exclusively during periods of anorexia nervosa.

Question 24

Give some complications of anorexia nervosa.

Answer 24

Cardiac arrhythmias due to electrolyte imbalance, hypotension, bradycardia.

Osteoporosis due to chronic malnutrition, amenorrhoea.

Gastroparesis and constipation.

Anaemia and leukopenia.

Lanugo hair growth and xerosis (dry skin).

Death due to multiorgan failure.

Question 25

Give 3 points described in the DSM-5 for the diagnosis of anorexia nervosa (3).

Answer 25

1. Restriction of eating leading to significantly low body weight in context of age, sex, developmental stage etc.
2. Intense fear of gaining weight.
3. Disturbance in body perception, unaware of own body weight or shape, undue weight on body image when considering sense of self.

Question 26

What management options are recommended by NICE for a) adults b) children and teenagers?

Answer 26

Adults:
Eating disorder focused CBT
MANTRA; Maudsley Anorexia Nervosa Treatment for Adults
SSCM; supportive specialist clinical management
These are all long term, 20-40 sessions, focusing on regaining weight, involving carers, helping to found healthy eating behaviours,

Children: anorexia based family therapy

AN is the most common cause for admission to psychiatric wards in child and adolescent services. Up to 10% of patients will die because of the disorder.

Medical risk / psychiatric risk e.g. suicide may require admission to medical unit or psychiatric unit respectively.

Question 27

Outline the ‘cycle’ observed in obsessive compulsive disorder.

Answer 27

1. Obsession
2. Anxiety
3. Compulsion
4. Temporary relief

Question 28

Some milder OCD cases can be managed with education and self help resources. What options are available for more severe cases?

Answer 28

CBT and ERP (exposure and response prevention)

SSRI

Clomipramine (TCA)

Question 29

What does a Section 2 order of the Mental Health Act involve?

Answer 29

Compulsory admission for assessment, following a MHA assessment.

Lasts up to 28 days.

Cannot be renewed, can only end in discharge or by putting a Section 3 order in place.

Question 30

What does a Section 3 order of the Mental Health Act involve?

Answer 30

Compulsory admission for treatment.
Lasts up to 6 months, but the responsible clinician can arrange to extend if required.
Detention under Section 3 requires a MHA assessment, can be from a Section 2 admission to a Section 3, or can be admitted from the community if the patient is well known to mental health services.

Question 31

What does a Section 4 order of the Mental Health Act involve?

Answer 31

Detention for 72 hours when necessary / urgent scenario and where other processes do not have time to be put in place.

It requires a AMHP and only one doctor. It is followed by a MHA assessment.

Often changed to a Section 2 on arrival to hospital.

Question 32

What does Section 136 of the Mental Health Act involve?

Answer 32

Used by the police to remove a person that appears to have a mental
health disorder from a public space to a place of safety to allow a MHA assessment to be carried out.
Lasts up to 24 hours.

Question 33

What do Section 5(2) and 5(4) orders of the MHA refer to respectively?

Answer 33

5(2); patient already in hospital voluntarily, used in an emergency to detain patients. Requires only 1 doctor, lasts 72 hours.

5(4); patient already in hospital voluntarily, used in an emergency to detain patients. Requires only 1 nurse to hold the patient for up to 6 hours.

Both are followed by a MHA assessment.

Question 34

What does Section 135 of the Mental Health Act involve?

Answer 34

Allows the police to break into a home to remove the person at risk to a place of safety for assessment.

Question 35

What does Section 17a of the Mental Health Act refer to?

Answer 35

Also known as CTO / Supervised Community Treatment.
Allows recall of the patient from the community to the hospital for treatment if not complying with the conditions of the order within the community e.g. taking medication.