Capsule cases Flashcards
A patient with a history of schizophrenia, currently mentally well, is taking the following:
- Risperidone 6mg BD
- Sodium Valproate 1000mg BD
- Citalopram 20mg OD
- Diazepam 5mg BD
He is complaining of a feeling of restlessness, with particularly restless legs, and comes to see you for advice. What is this called?
Akathisia
Give some examples of extrapyramidal side effects (EPSEs).
Akathisia is a very unpleasant sense of restlessness.
Tardive dyskinesia usually manifests as orofacial dyskinesias.
Parkinsonism presents with tremor, rigidity and bradykinesia.
Acute dystonic reaction can present with an oculogyric crisis and torticollis.
List some examples of typical vs atypical antipsychotics.
When is clozapine used in schizophrenia?
Only once other options have been trialled (e.g. olanzapine) and the schizophrenia is treatment resistant
True or False: Diazepam cannot be safely prescribed for more than 10 days due to the risk of addiction.
F
Guidelines state that benzodiazepines should ideally not be prescribed for longer than 2-4 weeks due to addictive potential.
Benzodiazepines are safe and extremely useful if used cautiously in the short-term.
How do you rule out a drug-induced psychosis?
Urine drug screen
Which medications would be appropriate to begin treatment for 1st episode psychosis?
- Fluoxetine 20mg OD
- Diazepam 5mg BD
- Olanzapine 10mg nocte
- Clozapine 200mg BD
- Aripiprazole 10mg OD
- Quetiapine 100mg OD
- Sodium Valproate 500mg BD
Olanzapine and Aripiprazole
These are adequate starting doses of atypical antipsychotics. While quetiapine is an antipsychotic, this dose is likely to be too low for psychosis. Clozapine is not first line.
Patient is given a number of different sedative medications during the admission, including haloperidol. He starts to develop a very painful muscular contraction on the left side of his neck. Which drug will best treat this side effect?
Procyclidine 10mg oral
What dose of lorazepam is initially used in sedation?
1mg PO
Promethazine (sedating antihistamine) is sometimes used 2nd line.
Can Section 5(2) be used to detain someone in A+E?
No, can only be used on a ward.
Which of the following drug lower seizure threshold for ECT?
- Diazepam
- Semi-sodium valproate
- Clozapine
- Zopiclone
- Magnesium
Clozapine - nearly all anti-psychotics and antidepressants will decrease the seizure threshold, making a fit more likely. It is important to take account of any medications when administering ECT, as many psychotropics can have an effect on the seizure threshold.
A patient ppears very low in mood and explains to you that she has become convinced that her insides have rotted away and no longer exist. How would you best describe this symptom?
Nihilistic dilusion - presents in those who are severely depressed
A pt sees a sees a psychiatrist who records the following unprompted speech verbatim: ‘I think I have problems. The history teacher knows all about it. My brother and I went fishing last weekend and we caught two mackerel. This room’s noisy isn’t it. The newsreader had a green shirt on. What time is it? I must see Steve later. Maths is just terrible, I can’t bear it. Sometimes I smoke, yeah’. What is this phenomenon called?
This is a classic example of loosening of association, or Knight’s move thinking, a formal thought disorder observed in psychosis where there are no clear links between successive thoughts.
Neologism is “made up words” and also seen in psychosis. In flight of ideas links are evident from thought to thought despite the topic regularly changing. It is more commonly seen in mania. Running commentary refers to an auditory hallucination common in psychosis.
What are the physical signs of withdrawal symptoms?
Hyperthermic temperature
Pulse rate above 100bpm
Respiration rate above 20bpm
Blood pressure variable, eg, starting off with hypertension in earlier phases of withdrawal followed by hypotension from fluid losses (sweating and hyperventilation)
Dilated pupils as a secondary effect of sympathetic hyperactivity
Palpitations
Musculoskeletal – Tremulous state and dehydration, potentially leading to muscle spasms and rhabdomyolysis
Neurologic – Tremors, increased deep tendon reflexes, ataxia, with or without dyskinesia
True or false: A paradoxical increase in hostility and aggression may be reported by patients taking benzodiazepines.
True - the effects range from talkativeness and excitement to aggressive and antisocial acts.
Adjustment of the dose (up or down) sometimes attenuates the impulses. Increased anxiety and perceptual disorders are other paradoxical effects
True or false: the benzodiadepine withdrawal syndrome should develop within a week of stopping a long acting benzodiazepine.
False - the benzodiazepine withdrawal syndrome may develop at any time up to 3 weeks after stopping a long-acting benzodiazepine, but may occur within a day in the case of a short-acting one
True or false: Benzodiazepines may cause dose-related anterograde amnesia.
True -significantly impairing the ability to learn new information whilst the retrieval of previously learned information remains intact. This effect is exploited when patients undergo uncomfortable procedures because comfort and postoperative amnesia are beneficial.
What are the symptoms of EUPD?
- mood instability,
- impulsivity
- relationship difficulties
manifest since childhood or adolescence
- It is associated with repeated self harm and suicidal tendencies.
- Social functioning and coping with adversity are often significantly impaired.
- Psychiatric co-morbidity is very common and often poses diagnostic difficulties.
What is the first line management of EUPD? What should be avoided?
- Refer to community mental health team (CMHT)
- Risk assessment is particularly important in EUPD. If the patient presents a high risk to them self or others, more urgent referral to psychiatric services is needed.
Drug treatment is generally not recommended unless there are co-morbid conditions requiring medication. Polypharmacy should be avoided.The aim is to reduce unnecessary drug treatment.
List factors which increase risk of completing suicide.
- Men are three times more likely to commit suicide.
- Being divorced,
- living alone ,
- being unemployed,
- belonging to lower social class,
- substance abuse and
- having terminal/chronic illness
puts one at a higher risk of completing suicide.
What are some protective factors against suicide? Which factors are important in prevention?
- Faith in a religion,
- social support and
- no substance abuse are protective factors.
Factors important in prevention are:
- treating the primary mental disorder,
- reducing the patient’s access to means to harm themselves, and
- educating the patient and carers about how/where to seek help in a crisis.
Are divorced or single people more likely to complete suicide?
Divorced
In in-patients, what stage is a patient at highest risk of suicide?
- First week of admission
- Later stage of recivery
- Within a month of discharge
- Bank holidays
- Being admitted as an inpatient
1, 3 and 4
In-patients are more likely to complete suicide in early stages of recovery, immediately following discharge and Bank Holidays.
Which is the following is the most common method of completed suicide in males in the UK?
Hanging/strangulation
In 2018, hanging/strangulation was the most common cause of death in males in the UK (59%). Self-poisoning was the second most common (18%).
What is the most common method of completed suicide in females in the UK?
In 2018, hanging/strangulation was the most common cause of death in females in the UK (45%). Self-poisoning was the second most common (36%).
What proportion of people who die by suicide have a mental illness?
What percentages of suicides have history of self-harm?
>90%
50%
True or false: Most patients with post natal depression can be safely treated at home
True
Indications for admission would be severe suicidality, psychotic features or risk to/neglect of baby.
Which antidepressant should not be used in pregnancy?
Paroxetine - preferred antidepressants in pregnancy are the SSRIs fluoxetine, sertraline, citalopram and escitalopram. Risk of untreated depression to mother and child is likely to be greater than the risk from fluoxetine.
What fetal abnormality is associated with lithium use?
Ebstein’s Anomaly, a serious cardiac anomaly - ~1 in 1000 babies exposed in first trimester affected
Which of the following drugs, when taken during pregnancy, has been associated with cleft lip in babies?
- Atypicals
- Typicals
- SSRIs
- TCAs
- Benzos
Benzodiazepines - 1st trimester exposure to benzodiazepines has been associated with increased risk of cleft lip, although this is not consistent across all studies.
Which two of the following are risk factors for post natal depression?
- multiparity
- hx of depression
- unplanned pregnancy
- single status
- FH of depression
Hx depression previously
FH of depression
An important specific risk factor for PND is having an unsupportive partner (National confidential enquiries into maternal deaths (DoH)).
Is psychiatric disorder the commonest cause of direct maternal death during pregnancy and in the year after pregnancy?
True
Whilst thromboembolism remains the leading cause of maternal death during pregnancy and the 6 weeks postpartum, suicide is the most common cause of death during pregnancy and the postpartum year.
When should the Edinburgh Postnatal Depression Scale be used?
Current NICE guidance (2014) recommends that women are asked two depression identification questions (about low mood and anhedonia) and are then given the Edinburgh Postnatal Depression Scale if they answer positively to one of them.
What is the Young Mania Rating Scale?
The Young Mania Rating Scale is useful to ascertain the severity of manic and psychotic symptoms at baseline
Which of these key side effects is linked to which drug?
- Increased appetite
- Sedation
- Tremor
- Tardive dyskinesia
- Headache
Drugs:
- Chlorpromazine
- Lithium
- Lorazepam
- Olanzapine
- Venlafaxine
Increased appetite - olanzapine
Sedation - lorazepam
Tremor - lithium
Tardive dyskinesia - chlorpromazine
Headache - venlafaxine
What criteria must a patient with postpartum psychosis meet to be discharged?
- The only essential criteria for discharge are that the patient is no longer judged to be a significant risk to herself or to her baby
+
- that she is willing to adhere to the treatment plan and has some degree of insight into her illness although this may not be essential
- Does not need to be completely free of psychotic symptoms.*
You decided you need to offer alternative management to a patient with GAD. Which pharmacological therapies could be considered for the long-term management of GAD? (3)
- Benzodiazepines
- Pregabalin
- Beta blocker
- Sedative antihistamines
- SSRI
- Venlafaxine
- Pregabalin
- SSRI
- Venlafaxine
Benzos should not be used for longer than 2-4 weeks at time and BB are only useful for the physical symptoms of anxiety.
Venlafaxine 150mg OD is a reuptake inhibitor of which two neurotransmitters?
- NA
- 5-HT
- At higher doses it also acts as a dopamine reuptake inhibitor
What is the third line treatment for GAD?
Venlafaxine
Which of the following benzodiazepines do you think would present the largest problem in terms of withdrawal?
- Diazepam
- Clonazepam
- Lorazepam
- Clobazam
- Chlordiazepoxide
Lorazepam
What are the effects of benzodiazepines?
Benzodiazepines potentiates the action GABA at the GABA-A receptor - this is an inhibitory neurotransmitter which decreases neuronal excitability
How do you discontinue a benzodiazepine?
Reduce dose in steps of 1/8th of the daily dose every 2 weeks
A 22-year-old male patient presents with recurrent episodes of an overwhelming sense of fear and anxiety. During these episodes, he experiences palpitations, nausea and shortness of breath. He sometimes feels tingling in his arms. The attacks usually last about 10 minutes. There is no relevant past medical history. He has been experiencing moderate stress at work. There are no abnormal findings on physical examination. What is the most likely diagnosis?
Panic disorder - The patient describes classic recurring panic attacks. About 1 person in 50 suffers with panic disorder.There is no history of acute stress or depressive symptoms. GAD presents with more continuous excessive anxiety and worry
Which of the following are typical features of obsessional thoughts? (3)
- They are usually resisted
- They are egosyntonic
- Sexual content is unusual
- They are typically intrusive and repetitive
- They can occur in depressive disorders
1, 4, 5
Are egodystonic (very different to the patient’s normal beliefs and values) and sexual content is not unusual
Obsessive thoughts can found when experiencing a depressive episode, and sometimes there is full OCD as a secondary diagnosis.
What is the first and second line treatment for OCD?
Sertraline (increased fairly quickly to maximum dose
Clomipramine (TCA) has high selectivity for 5HT and is 2nd/3rd line
Antipsychotics (eg aripiprazole, risperidone) are sometime added to an SSRI as an adjunctive treatment 3rd/4th line
What are the diagnostic features for anorexia nervosa?
- Low body weight (below 85% of median weight for height/BMI below 17.5)
- Deliberate measures to lose weight/keep weight low, including dietary restriction and/or excess calorie loss
- Morbid fear of fatness (this may be overvalued ideas they are larger than they are; or fear of gaining weight when they are underweight)
- Endocrine disturbance, commonly manifested as amenorrhoea in women
What % of patients with anorexia nervosa make a full recovery in 20 years?
50%
15% die of complications of anorexia nervosa
What are the most common reasons for admission in anorexia nervosa?
HR <40
Long QTc
Refeeding syndrome
Significant suicidal thinking
Rapid weight loss - MARSIPAN guidelines assess physical risk
What are some electrolyte abnormalities in Bulimia nervosa?
- Hypokalaemia - can cause cardiac arrhythmia
- Hypocalcaemia
- Hypotension
- Decreased RBC count
- Metabolic alkalosis - caused by vomiting
Lithium reduces suicide risk.
True or false?
True
What is the appropriate management of EUPD?
- Give a small dose of antipsychotic
- Stop antidepressants
- Prescribe diazepam
- Refer to CMHT
4 - it is difficult to stop medication in these patients once it has been started as they become attached to it.
Compared to the general population what is the risk increase of suicide in those with EUPD?
8% more likely to commit suicide than general population
What are the main features of these conditions:
- Delirium
- Vascular dementia
- DLB
- FTD
Delirium = fluctuating consciousness, sudden onset, reduced attention, disturbance of sleep-wake cycle and possible underlying medical cause e.g. infection.
Vascular dementia = sudden onset, step-wise decline and history of vascular disease e.g. hypertension.
DLB= prominent visual hallucinations, parkinsonism and relative sparing of STM.
FTD = prominent early changes in interpersonal behaviour (including disinhibition), apathy, blunting of emotions, lack of self-care, and language deficits – memory changes tend to be later
