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MRCPsych Part B - Al-Rashid Hospital > Adult Psychiatry 2 > Flashcards

Adult Psychiatry 2 Flashcards

1
Q

How many adults in the UK have ‘broadly defined neurosis’ at any one time?

A

15%

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2
Q

Most common anxiety disorders in the UK

A

Mixed anxiety-depression

GAD

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3
Q

How many GP consultations are for anxiety related sx?

A

25%

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4
Q

Mean age of onset of GAD

A

30

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5
Q

Mean age of onset of panic disorders

A

22-25

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6
Q

Mean age of onset of OCD

A

20

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7
Q

Mean age of onset of social phobia

A

15

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8
Q

Mean age of onset of phobia of blood injury injection or environmental types

A

5-9 years

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9
Q

Mean age of onset of situational phobias

A

20 years

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10
Q

What has been noted about the dx of anxiety disorders and age?

A

With each generation, anxiety disorders are diagnosed at a younger age than previous

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11
Q

Lifetime prevalence of blood-injection-injury phobia

A

3.5%

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12
Q

What do subjects with blood-injury-injection phobia have a higher lifetime hx of?

A

Fainting

Seizures

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13
Q

In which groups is prevalence of blood-injury-injection lower?

A

Elderly

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14
Q

In which groups is prevalence of blood-injury-injection higher?

A

Females

Less education

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15
Q

Which anxiety disorder is most common in boys?

A

OCD

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16
Q

Which anxiety disorder has equal distribution between men and women?

A

OCD

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17
Q

In which anxiety disorder do men outnumber women in attending health centres?

A

Social phobia

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18
Q

What do NICE recommend is needed first before treating anxiety disorders?

A

Comprehensive assessment considering distress, functional impairment, effect of co-morbid MI, substance misuse or medical conditions and previous response to treatment

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19
Q

First line treatment for anxiety disorders

A

Psychological therapy first

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20
Q

Which pharmacological therapy is advised for anxiety disorders?

A

SSRIs

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21
Q

When to consider combination therapy for anxiety disorders?

A

Complex anxiety disorders refractory to treatment

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22
Q

Point prevalence of OCD in adults

A

1-3%

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23
Q

Point prevalence of OCD in children

A

1-2%

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24
Q

Lifetime prevalence of OCD

A

2-3%

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25
Q

Most commonly prevalent psychiatric disorders?

A 
Phobias
Alcohol misuse
Depression
OCD
(in that order)
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26
Q

Gender ratio of OCD in community

A

1.5:1 female:male

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27
Q

Why is it thought that there is a greater ratio of women with OCD in the community despite equal gender ratio of the disease?

A

Men have more severe psychopathology

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28
Q

Difference in OCD between males and females

A

Men show earlier onset and trend more towards tics and poorer outcome

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29
Q

Who created the four factor model of OCD?

A

Castle & Phillips 2006

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30
Q

What is the four factor model of OCD?

A

Aggressive, sexual and religious obsessions and checking compulsions
Symmetry and ordering obsessions and compulsions
Contaminatino obsessions and cleaning compulsions
Hoarding obsessions and compulsions

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31
Q

Which obsessions & compulsions are often chronic and treatment resistant?

A

Symmetry ordering often chronic and Rx resistant

Hoarding often Rx resistant

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32
Q

Which obsession/compulsion may be neurobiologically ditinct?

A

Hoarding

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33
Q

What neurobiology has been reported in OCD?

A

Hypermetabolism of basal ganglia structures i.e. caudate

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34
Q

Which medications can cause OCD sx?

A

D2 antagonists such as clozapine and other antipsychotics

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35
Q

Which children have higher rates of OCD?

A

Children with autoimmune reactions

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36
Q

What can OCD spectrum disorders be classified into?

A

Somatic preoccupation e.g. anorexia
Neurological disorders e.g. Tourettes
Impulse control disorders e.g. paraphilias
Anankastic PD

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37
Q

What does PANDAS stand for?

A

Paediatric autoimmune neuropsychiatric disorders associated with strep infection

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38
Q

What is PANDAS?

A

Thought to be secondary to streptococcal infection and mediated by autoantibodies binding to basal ganglia.

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39
Q

What sx does PANDAS produce?

A

Tics
Fluctuating OCD sx
Anxiety

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40
Q

NIMH diagnostic criteria for PANDAS

A

Presence of OCD or a tic disorder
Onset between 3 years of age and beginning of puberty
Abrupt onset of sx or a course characterised by dramatic exacerbations of sx
Onset of exacerbation of sx temporally related to infection with GABHS
Abnormal neuro exam during exacerbation

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41
Q

What is GABHS?

A

Group A beta-haemolytic strep infection

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42
Q

What is found to be elevated in those with PANDAS?

A

AntiDNAseB or Antistreptolysin O titres

Some may have autoantibodies to neurons in basal ganglia; called basal ganglia antibodies

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43
Q

Treatment for mild-moderate OCD (first line)

A

Self-help

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44
Q

2nd line treatment for mild-moderate OCD

A

CBT with ERP (Exposure and response prevention)

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45
Q

3rd line treatment for mild-moderate OCD

A

SSRIs +/- CBT

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46
Q

1st line treatment for severe OCD

A

SSRIs+/-CBT

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47
Q

How long do people with severe OCD need to continue SSRIs if they respond well?

A

1-2 years +/- booster CBT

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48
Q

2nd line treatment for severe OCD

A

Switch to different SSRI or clomipramine

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49
Q

What is exposure and response prevention?

A

Element of CBT for OCD

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50
Q

What happens in exposure and response prevention?

A

Patients are trained to confront (directly or imaginative) anxiety-provoking situations while abstaining from compulsive behaviours in response.

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51
Q

Evidence for ‘booster’ sessions of ERP for OCD?

A

Can reduce risk of relapse and provide more durable remission than pharmacotherapy alone

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52
Q

What type of medications does OCD respond well to?

A

Serotonergic medications i.e. SSRIs, clomipramine.

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53
Q

How many patients with OCD show some sort of improvement to SSRI?

A

60-70%

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54
Q

NNT for SSRI for OCD?

A

6-12

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55
Q

When is antipsychotic augmentation with SSRI considered for OCD?

A

If no response after 3 month trial of maximal dose of SSRI.

Particularly useful if tics.

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56
Q

What has happened to PTSD diagnosis in DSM V?

A

Criteria changed
Moved from anxiety disorders into ‘trauma and stressor-related disorders’
Clinical subtype ‘dissociative sx’ added

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57
Q

Diagnostic criteria for PTSD for DSM V

A

Hx of exposure to traumatic event that meets specific stipulations and sx from each of 4 clusters:
Avoidance
Negative alterations in cognitions and mood
Alterations in arousal
Reactivity

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58
Q

Point prevalence of PTSD

A

1%

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59
Q

Incidence of PTSD worldwide?

A

Varies

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60
Q

Lifetime prevalence of PTSD in America for adults?

A

6.8%

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61
Q

Lifetime prevalence of PTSD in men vs women

A

Men: 3.6%
Women: 9.7%

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62
Q

Which gender is more likely to be exposed to traumatic events?

A

Men: 60%
Women: 50%

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63
Q

How many people exposed to trauma will develop PTSD?

A

30%

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64
Q

Most frequently experienced trauma?

A 
Witnessing someone being badly injured/killed
Exposure to fire/flood/natural disaster
Involved in life-threatening accident
Combat exposure
(in that order)
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65
Q

Which gender is molestation more common in?

A

Females

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66
Q

Which gender is mugging more common in?

A

Males

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67
Q

In which type of trauma do men develop more PTSD?

A

Rape

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68
Q

Which age group is more likely to develop PTSD?

A

Younger

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69
Q

In which type of patients is PTSD more common?

A

Younger
Those with higher anxiety response to initial event
Those who perceive external locus of control

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70
Q

What does NICE recommend re PTSD initially?

A

Primary care diagnosis and screening as likely underdiagnosed

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71
Q

Who did research into factors associated with PTSD?

A

Bisson 2007

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72
Q

Pre-traumatic factors of PTSD?

A 
Previous psychiatric disorder
Female
Personality - external locus of control
Lower socioeconomic & educational status
Etnic minotiry
Cluster B PD
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73
Q

Peritraumatic factors for PTSD?

A

Higher severity of trauma
Perceived threat to life
Peritraumatic dissociation

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74
Q

Post-traumatic factors for PTSD?

A

Perceived lack of social support

Subsequent life stress or physical illness - especially chronic pain

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75
Q

Protective factors for PTSD?

A

High IQ
Higher social class
Opportunity to grieve for loss

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76
Q

Which areas of the brain show abnormalities in PTSD?

A

Hippocampus

Amygdala

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77
Q

What type of metabolic disturbance is shown in PTSD?

A

Hypocortisolaemia

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78
Q

What features predict chronicity in PTSD?

A

Strong avoidance features

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79
Q

Which interventions have been shown to be beneficial for PTSD?

A

Multiple-session CBT to prevent PTSD in people with acute stress disorder

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80
Q

Which interventions are unlikely to be beneficial in PTSD?

A

Single-session individual debriefing to prevent PTSD

Supportive counselling to prevent PTSD

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81
Q

NICE guidelines for initial management of PTSD in primary care

A

Watchful waiting if sx are mild and present for <4 weeks after trauma

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82
Q

When does NICE recommend px of non-benzo sleeping tablet for PTSD in primary care?

A

After 4 consecutive nights sleep disturbance

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83
Q

NICE Guidelines for PTSD in secondary care

A

Psychological treatment regularly and continuously (once a week) by the same person

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84
Q

What does NICE specifically not recommend for PTSD management in secondary care?

A

Non-trauma focused interventions such as relaxation/non-directive therapy

85
Q

NICE guidelines for PTSD management in secondary care if sx present within 3 months of trauma

A

Trauma-focused CBT

86
Q

What does trauma-focused CBT include?

A

Exposure therapy
Cognitive therapy
Stress management

87
Q

When should trauma-focused CBT be offered?

A

Those with severe PTSD
Those with severe PTSD in first month after traumatic event
Those with PTSD within 3 months of event

88
Q

How is trauma-focused CBT delivered?

A

OP; 8-12 sessions (5 if treatment starts within 1 month of event)

89
Q

Guidance for long-term use of sleeping medication for PTSD

A

Antidepressant

90
Q

NICE guidelines for PTSD if sx present for more than 3 months after trauma

A

Trauma-focused CBT or EMDR

91
Q

How many sessions of trauma-focused CBT or EMDR are offered for PTSD sx >3 months after trauma?

A

12 sessions

92
Q

What to offer if treatment failure or limited improvement with therapy and sx >3 months after trauma?

A

Alternative form of trauma-focused psychological treatment; if no further improvement, consider pharmacological treatment

93
Q

Pharmacological treatment for general use for PTSD

A

Paroxetine

Mirtazapine

94
Q

Pharmacological treatment for specialist use for PTSD

A

Amitriptyline

Phenelzine

95
Q

Which medication is licensed for females only with PTSD?

A

Sertraline

96
Q

NICE second line options for PTSD (pharmacotherapy)

A

Paroxetine

Mirtazapine

97
Q

Which medication has evidence of good effect if used as augmentation for PTSD?

A

Olanzapine

98
Q

Evidence re psychological debriefing after trauma?

A

Equivalent to or worse than control or educational interventions in preventing PTSD and general psychological morbidity post-trauma.
May increase risk of PTSD & depression.

99
Q

Evidence re psychological therapies for PTSD?

A

No difference between trauma-focused CBT and EMDR
Both are superior to stress management
Stress management superior to other therapies

100
Q

What happens in exposure therapy as part of trauma-focused CBT?

A

Repeated confrontation of traumatic memories and repeated exposure to avoided situations take place together with relaxation and anxiety reduction

101
Q

When happens in the cognitive component of trauma-focused CBT?

A

Modification of misinterpretations that lead to overestimation of current threat and modification of other beliefs related to trauma experience and individuals behaviour during trauma (such as guilt) are attempted via cognitive restructuring.

102
Q

Who discovered EMDR and how?

A

Shapiro; used it on herself

103
Q

What theory is EMDR based on?

A

Bilateral stimulation in the form of eye movements allows processing of traumatic memories.

104
Q

What happens during EMDR?

A

While patient focuses on specific images, negative sensations and associated cognitions, bilateral stimulation is applied to desensitise the individual to these memories and more positive sensations and cognitions are introduced.

105
Q

Outcome results for PTSD with treatment?

A

More than a third of people report having the disorder after 6 years.

106
Q

Remission of PTSD?

A

50% at 2 years

107
Q

Diagnostic criteria for acute stress disorder?

A

Immediate and clear temporal connection between impact of stressor and onset of sx
Sx usually appear within minutes and disappear within 2-3 days (often hours)
Partial or complete amnesia for episode may be present.

108
Q

Further sx required for acute stress disorder?

A

Sx show mixed and changing picture

Sx resolve rapidly (hours) when removal of stressful situation is possible; when continued, sx diminsh in 24-48h.

109
Q

What type of sx are seen in acute stress disorder?

A

Initial state of ‘daze,’ depression, anxiety, anger, withdrawal.

110
Q

When should dx of acute stress disorder not be used?

A

To cover sudden exacerbation of sx in individuals already showing sx that fulfull criteria for any other psychiatric disorder

111
Q

Which sx is not needed for GAD which is usually needed for other anxiety disorders?

A

Avoidance

112
Q

Lifetime prevalence of GAD

A

5%

113
Q

Point prevalence of GAD

A

2-3%

114
Q

MZ vs DZ concordance of GAD?

A

41% vs 4% (MZ vs DZ)

115
Q

Risk factors for GAD?

A 
Exposure to civilian trauma
Bullying
Higher number of life events
Being first-degree relative of GAD patient
Female
116
Q

What is Hamilton anxiety scale?

A

14-item scale

Emphasises somatic sx

117
Q

Definition of treatment response for GD

A

50% reduction in baseline score on Hamilton anxiety scale

118
Q

Definition of clinical recovery of GAD

A

<7 on Hamilton anxiety scale

119
Q

Acute treatment of GAD

A 
SSRI
TCAs
Benzos
CBT
Venlafaxine, Duloxetine & Buspirone
120
Q

Which SSRIs can be used for GAD?

A

Escitalopram
Paroxetine
Sertraline

121
Q

Which TCAs can be used for GAD?

A

Imipramine

122
Q

Which Benzos can be used for GAD (Short-term)?

A

Alprazolam

Diazepam

123
Q

Treatment for long-term management/prevention of GAD?

A 
CBT
Paroxetine
Escitalopram
Venlafaxine
Pregabalin
124
Q

Adjuncts for non-response for GAD

A

Olanzapine/Risperidone at low dose

125
Q

First line treatment for GAD as per NICE?

A

SSRI or SNRI or Pregabalin

126
Q

Which type of CBT is recommended for GAD?

A

Education
Relaxation training
Exposure and cognitive restructuring

127
Q

Guidance re combination of medication and psychological therapy for GAD?

A

Insufficient evidence but can be used if initial treatment fails

128
Q

Outcome for GAD

A

42% patients recover after 12 years

129
Q

Which patients show poorer outcomes for GAD?

A

Those with another anxiety disorder

130
Q

Which herbal drug has been shown to be effective for GAD?

A

Kava shrub (Piper methysticum)

131
Q

How does kava work?

A

Due to kavapyrones which in animals act as muscle relaxants and anticonvulsants and reduce limbic system exciability

132
Q

How might kava work?

A

Inhibition of voltage-dependent Na channels
Increase GABAA receptor densities
Block norepinephrine reuptake
Suppress release of glutamate

133
Q

Research re kava for GAD

A

Kava is more effective than placebo in reducing HAM-A scores, effect is detectable for 1 week

134
Q

Why is kava not recommended for clinical use for GAD in the UK?

A

Associated with hepatotoxicity

135
Q

Which medications can Kava interact with?

A

Levodop
Alprazolam
Can cause EPSEs or lethargy

136
Q

Which medications can the herb Valerian interact with?

A

Loperamide and fluoxetine, causing delirium

137
Q

Which medications can evening primrose oil interact with?

A

Phenothiazides, causing epileptic seizures

138
Q

Point prevalence of social phobia?

A

2.8%

139
Q

Who recognised two types of social phobia?

A

Schneier 2003

140
Q

What are the two types of social phobia?

A

Generalised

Situational

141
Q

What is generalised social phobia?

A

Fear occurs in most social situations

142
Q

What is situational social phobia?

A

Fear occurs in public speaking or performance anxiety

143
Q

First line pharmacotherapy for Social phobia?

A 
Paroxetine
Sertraline
Fluoxetine
Fluvoxamine
Escitalopram
Venlafaxine
144
Q

Duration of medication for social phobia (first line)

A

12 weeks

145
Q

How long should drug treatment continue if good response for social phone?

A

6-12 months

146
Q

2nd line treatment for social phobia?

A

Phenelzine

147
Q

3rd line treatment for social phobia?

A

SSRI + Clonazepam combination
Gabapentin
Pregabalin

148
Q

Which social phobia can beta blockers be used for?

A

Performance anxiety

149
Q

How does DSM categorize panic disorder?

A

Primary dysfunction

150
Q

How does ICD categorize Panic Disorder?

A

Agoraphobia

151
Q

Point prevalence of panic disorder

A

0.9%

152
Q

Lifetime prevalence of panic attacks

A

28%

153
Q

Lifetime prevalence of panic disorder

A

4.7%

154
Q

Mean age of onset of any panic attack

A

22 years

155
Q

Mortality rate of panic disorder

A

All-cause mortality increased by 1.9 times

156
Q

How does ICD 10 classify panic disorder?

A

Recurrent, unpredictable panic attacks with sudden onset of palpitations, CP, choking sensation, dizziness and feelings of unreality, often associated with fear of dying/losing control but w/o requirement for sx to have persisted >1 month.

157
Q

Heritability estimate of panic disorder

A

30-40%

158
Q

Cognitive theory of patients with panic disorder?

A

Patients have heightened sensitivity to internal bodily sensations.

159
Q

What does neuroimaging suggest re panic disorder?

A

Involvement of fear network: amygdala, orbitofrontal cortex and hyporthalamus

160
Q

First line drug treatment for panic disorder

A

SSRI

161
Q

First line treatment for panic disorder

A

7-14 weeks of CBT (weekly 1-2 hours) completed within 4 months
SSRI
Bibliotherapy

162
Q

Recommendation if no effect with 12 week course of SSRI for panic disorder

A

Imipramine

Clomipramine

163
Q

Benzo use in panic disorder?

A

Associated with worse outcome; should not be used

164
Q

BAP recommendation for panic disorder

A 
CBT
All SSRIs
Clomipramine, Imipramine
Venlafaxine
Reboxetine
Benzos
165
Q

Which benzos does BAP recommend for panic disorder?

A

Alprazolam
Clonazepam
Diazepam
Lorazepam

166
Q

Efficacy of meds vs therapy for panic disorder?

A

Both have equal efficacy

167
Q

How long do SSRIs need to be continued for panic disorder to assess efficacy?

A

12 weeks

168
Q

Long-term treatment for panic disorder?

A

Cognitive therapy with exposure

Drug treatment for 6 months if good response

169
Q

Best treatment to reduce relapse of panic disorder?

A

Cognitive therapy with exposure

170
Q

First line drug treatment for long term treatment of panic disorder

A

SSRI

171
Q

2nd line drug treatment for long term treatment of panic disorder

A

Imipramine

172
Q

Recommendations if initial therapy fails for panic disorder

A

Add Paroxetine or Buspirone to psychological treatment if partial response
Add Paroxetine while continuing CBT if no response

173
Q

How is Hypochondriasis classed in ICD 10?

A

Preoccupation with fear of having a serious disease based on misrepresentation of bodily sx.

174
Q

How is hypochondriasis classed in DSM V?

A

Removed due to pejorative perception; now diagnosd as Somatic Symptom Disorder or Illness Anxiety Disorder

175
Q

Prevalence of Hypochondriasis

A

0.8-4.5%

176
Q

Treatment for Hypochondriasis

A

CBT
Group CBT
SSRIs

177
Q

What happens to patients with Body dysmorphic disorder (BDD)?

A

Patient is convinced that part of their body has a defect or is flawed.
Patient engages in repetitive behaviours or mental acts in response to preoccupations about perceived flaws.

178
Q

What can BDD be divided into?

A

Psychotic

Non-psychotic

179
Q

What can BDD be classified into in DSM V?

A

With or w/o delusional component; characterised by spectrum of insight

180
Q

Factors that predispose an individual to BDD

A

Low self-esteem
Critical parents and significant others
Early childhood trauma
Unconscious displacement of emotional conflict

181
Q

What do patients with BDD also tend to have?

A 
Earlier onset of depression (26%)
Social phobia (16%)
OCD (6%)
Pyschotic disorder
Higher rates of substance use in first-degree relatives.
182
Q

How many patients with BDD seek cosmetic surgery?

A

7-15%

183
Q

Treatment for BDD

A

High dose SSRIs for longer than usual antidepressant trial

184
Q

Best medication therapy for BDD?

A

Fluoxetine

185
Q

Treatment for treatment-resistant BDD?

A

Fluoxetine with CBT

186
Q

Outcome of BDD

A

Poor, with waxing/waning course.

Preserved psychosocial functioning in line with persistent delusional disorders

187
Q

Prevalence rate of somatisation disorder

A

1-2%

188
Q

Gender ratio of somatisation disorder

A

2:1 female:male

189
Q

What do patients with medically unexplained symptoms also have high prevalence of?

A

Undiagnosed mental disorder

190
Q

What did Rohricht and Elanjithara (2009) find re MUS?

A

42% of patients with MUS have primary diagnosis of somatoform disorder
36% had depression medicated by effect of somatic sx

191
Q

What is emphasis of diagnosis of somatic symptom disorder on?

A

Maladaptive thoughts and feelings and behaviours associated with somatic symptoms

192
Q

Who did a review into treatment of somatic symptom disorder?

A

Sumathipala et al 2007

193
Q

Treatment options for somatic symptom disorder

A

Antidepressants
CBT
Nonspecific inerventions

194
Q

Which treatment option has best evidence for somatic symptom disorder?

A

CBT

195
Q

What type of somatic symptom disorder is CBT best for?

A

MUS

196
Q

How does CBT help in MUS?

A

Reduces physical sx, psychological distress and disability

197
Q

Treatment recommendation for somatic symptom disorder in primary care?

A

Collaborative care models

198
Q

Which type of therapy is recommended for somatic symptom disorder?

A

CBT
Body-oriented psychological therapy
Mentalization-based CBT
Brief psychodynamic interpersonal therapy

199
Q

What does ICD 10 classify conversion dsorder as?

A

Dissociative disorder

200
Q

What does DSM V list as dissociative disorders?

A

Dissociative identity disorder
Dissociative amnesia
Depresonalisation/dereleaisation disorder

201
Q

What is Dissociative fugue classed under in DSM V?

A

Dissociative amnesia

202
Q

What is dissociative identity disorder?

A

Distinct alternation of two or more distinct personality states with impaired recall between these states

203
Q

What is dissociative amnesia?

A

Temporary loss of recall memory (specifically episodic) due to traumatic or stressful event

204
Q

What is dissociative fugue

A

Reversible amnesia for personal identity, usually involving unplanned travelling sometimes established by new identity

205
Q

Prevalence of dissociative disorder in adults

A

10%

206
Q

Who is dissociative disorder more common in?

A

Females
Those with anxiety, mood and substance misuse disorders
Childhood trauma

207
Q

Aim of treatment for dissociative disorders

A

To integrate feelings, perceptions, thoughts and memories

208
Q

Recommendation for treatment of dissociative disorder?

A

Individual psychotherapy; especially structured therapy such as Acceptance and Commitment therapy & DBT

MRCPsych Part B - Al-Rashid Hospital (64 decks)

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