Capsule PSYCHIATRY Flashcards
1
Q
Which is more indicative of schizophrenia: A 2nd person auditory hallucination or 3rd person auditory hallucination?
A
Third person auditory hallucinations are first ranks symptoms of schizophrenia.
These can include the perception of voices discussing the patient or giving a running commentary.
2
Q
What is an example of 3rd person auditory hallucination?
A
The perception of people discussing the patient or giving a running commentary
3
Q
What are the four first ranks symptoms of schizophrenia?
A
- Delusional perception
- Auditory hallucination
- Delusion of thought interference
- Passivity phenomena (also delusion of control)
4
Q
What is passivity phenomena and in what context might it be experienced?
A
The feeling of being controlled by an external force, this can take the form of:
- impulses
- actions
- feelings
- somatic passivity
it is a component of schizophrenia and psychosis
5
Q
List the main components of the mental state examination
A
A&B STM PCI
- appearance and behaviour
- speech
- thought
- mood
- perception
- cognition
- insight
6
Q
In the mental state examination what are the specific areas of speech that should be assessed:
A
- Rate and flow
- quantity
- tone and volume
- fluency
7
Q
In a acutely agitated patient what oral agents are commonly used as first-line tranquilization/servation?
A
- Oral benzodiazepine e.g. Lorazepam 1mg PO
- oral haloperidol
8
Q
Torticollis presents as a
A
Acute dystonia of the neck affecting the sternocleidomastoid muscle
9
Q
Torticollis is and extrapyramidal side effect of what class of drug
A
Typical antipsychotics
10
Q
What class of drugs can be used to treat torticollis (as a side effect to a anti psychotics)
A
Anticholinergic medication e.g. procyclidine
11
Q
How long does a section 5(2) allow for patient to be held on the ward for?
A
Up to 72 hours
12
Q
Can a section 5(2) be used in A&E?
A
No
only applicable once a patient has been admitted to the ward
13
Q
What are the three core symptoms of depression:
A
- Depressed mood
- loss of interest
- anhedonia (loss of pleasure)
14
Q
For major depression disorder to be diagnosed what are some symptoms that may be present?
(At least five)
A
- Depressed mood
- diminished interest or pleasure
- change in weight/appetite
- insomnia or hypersomnia
- psychomotor agitation or retardation
- fatigue or lack of energy
- feelings of worthlessness
- excessive or inappropriate guilt
- diminished ability to think or concentrate
- indecisiveness
- recurrent thoughts of death
- suicidal ideation
in addition the symptoms must be causing functional impairment e.g. social or occupational and should be explained better by substance abuse, medication side effects or other psychiatric or somatic medical conditions
15
Q
In a patient with confirmed moderate to severe depression what would be considered the optimum treatment?
A
Combination therapy with antidepressants and high-intensity psychological intervention
(SSRIs such as sertraline and therapy such as CBT)
16
Q
Hypochondriasis is a
A
Overvalued idea that you have a particular serious illness
17
Q
Somatic passivity is
A
The belief that external forces are making you feel bodily sensations
18
Q
Severely depressed patients may develop mood congruent/mood incongruent disorders?
A
Mood congruent e.g. nihilistic delusions
19
Q
Do antipsychotics increase or decrease seizure threshold
A
Nearly all antipsychotics and antidepressants will decrease seizure threshold
this is especially important when administering ECT
20
Q
Wernick’s encephalopathy is a result of deficiency
A
Thiamine deficiency (B1)
21
Q
Confusion, ataxia and nystagmus are a common triad of what condition?
A
Wernick’s encephalopathy
22
Q
Treatment of Wernick’s encephalopathy should be initiated with
A
Parenteral thiamine
23
Q
Treatment of Wernick’s encephalopathy should be initiated with
A
Parenteral thiamine
24
Q
Delirium tremens is usually caused by?
A
Rapid withdrawal from alcohol
25
What is the usual timeframe for delirium tremens
Often around day three of withdrawal from alcohol
26
What is the usual treatment for delirium tremens
Benzodiazepines are the mainstay and should also be withdrawn slowly
antipsychotics may be occasionally necessary however caution is needed as they can reduce seizure threshold
27
What syndrome can follow Wernick's encephalopathy?
(Likewise due to thiamine deficiency)
Korsakoff's syndrome
28
Korsakoff syndrome can occur after a patient presents with Wernick's encephalopathy, how might a present?
* Marked retrograde and anterograde grade amnesia with confabulation
* classically accompanied by a lack of insight and apathy
29
is a psychological therapy technique used in substance misuse services
Motivational interviewing
30
Can Methadone be used for sustained analgesia in patients with a substance misuse problem?
No. Methadone connect as an analgesia 4 to 8 hours however it works as a suppressive opioid withdrawal for 24 to 48 hours
31
Should intramuscular or intravenous morphine be avoided in patients that are on methadone for heroin addiction due to the risk of respiratory and CNS depression?
No, while attention needs to be paid and correct dosage can be challenging these patients can develop tolerance to the depressive effects of opioids and in fact can develop hyperalgesia and therefore may require higher levels of opioids
32
Iv opioids should be avoided in all circumstances in patients recovering from IV drug use **_true or false_**
False, there is currently no evidence that IV morphine necessarily triggers relapse. Some theories suggest that the stress associated with unrelieved pain however can trigger relapse
33
Naloxone = antidote
Naloxone = opioid antidote
34
Flumazenil = antidote
Benzodiazepine antagonist
35
In terms of duration of action what needs to be taken in consideration when using naloxone
It has a short half life than most opiates therefore patient should be monitored even if they appear to show a full recovery
36
In terms of Opioid withdrawal when do the symptoms first appear and how long can they last?
Withdrawal starts in 6 to 24 hours and can last between five and seven days.
Peak of symptoms can occur on the second or third day.
37
What are some classic symptoms of opioid withdrawal?
* Agitation
* anxiety
* dilate the pupils
* sweating
* tachycardia
* hypertension
* piloerection
* yawning
* cool clammy skin
* watering of the eyes and nose
38
Buprenorphine mechanism of action =
Partial opiate agonist
39
Methadone is a
Long acting synthetic opiates
40
Lofexidine can be used to help with the symptomatic relief in opiate withdrawal, what's is mechanism of action
Alpha-2 adrenergic agonist
41
In terms of opioid withdrawal Buprenorphine should be used before or after the initiation of withdrawal
Buprenorphine should not be started until withdrawal symptoms of started or it may trigger a withdrawal syndrome.
Buprenorphine works by acting as a partial opioid receptor agonist, this stops heroin leading to further receptor activation and intoxication
42
Suicide risk
when are in-patients more likely to complete suicide?
* In the early stages of recovery
* immediately following discharge
* bank holidays
43
What are the first and second most common methods for complete suicides
(male and female)
1. Hanging/strangulation
2. self poisoning
44
What is the single greatest predictive risk factor for a person to go on to have a completed suicide
History of Self-harm
45
What is the most common serious infection found in IV drug users
Hepatitis C
46
AUDIT PC (5 questions) and FAST (4 questions) are screening tools used to detect what?
Levels of alcohol consumption/hazardous, harmful drinking
47
What are symptoms of acute alcohol withdrawal?
* Tremor
* sweating
* nausea and vomiting
* agitation, anxiety
* insomnia
48
What are the three key interventions to consider in patients undergoing acute alcohol withdrawal:
* Thiamine
* Benzodiazepines
* admission to hospital (in patients with high risk of seizures or delirium tremens and in patients who are vulnerable)
49
For a panic disorder what is the first-line treatment
CBT
50
For a panic disorder in which the CBT does not prove completely effective what additional treatment is likely to be tried first
SSRI
(beta-blocker's may be used to help attacks, and benzodiazepine and sedating antihistamines may also be trialled for acute attacks)
51
Generalised anxiety disorder is more common in which demographic?
(Age and gender)
Women, 30-50 years
52
Beta-blocker's helpful for the long-term treatment of GAD?
Beta-blockers are only helpful for the physical symptoms of anxiety
53
What medication used for neuropathic pain can also be used for generalised anxiety disorder?
Pregabalin
54
Mood instability, impulsivity and relationship difficulties manifesting since childhood are signs of?
Emotionally unstable personality disorder
55
Describe the core components of EUPD
Emotionally unstable personality disorder (EUPD) is characterised by symptoms of mood instability, impulsivity and 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.
56
What pharmacological treatments are recommended as first-line for EUPD
(emotionally unstable personality disorder)
Drug treatment is generally not recommended unless there are co-morbid conditions requiring medication.
Polypharmacy should be avoided.
57
What is the appropriate first step in the management of a patient presenting to her GP with emotionally unstable personality disorder?
It is important to establish the diagnosis, the GP should refer to the community mental health team and mention suspected EUPD in the letter.
58
Why are risk assessments essential in deciding on treatment pathways for patients with emotional unstable personality disorder?
It is associated with repeated self-harm and suicide tendencies, there are also often psychiatric comorbidities that are present.
59
Borderline Personality disorders are more likely to commit suicide, by what %?
Borderline personality disorders are more likely to commit suicide by 8% compared to the general population. A further assessment of risk is indicated.
60
In terms of alcohol dependence what is meant by primacy of substance seeking behaviour?
Alcohol has become the most important thing in that person's life and takes priority over other interests
61
What are some features of substance dependence?
(8)
* Loss of control of consumption
* continued use in spite of negative consequences
* narrowing of repertoire
* primacy of substance seeking behaviour
* rapid reinstatement
* substance taking to avoid withdrawal symptoms
* tolerance
* withdrawal
62
correctly define one unit of alcohol?
One unit of alcohol is defined as “amount of alcohol that an adult can metabolise in 1 hour which is equivalent to about 10 ml of pure ethanol or 8g of pure ethanol.”
63
Which neurotransmitters are believed to play a role in the CNS effects of alcohol?
Enhancement of Gaba-A (anxilolytic effect)
Release of Dopamine in mesolimbic system (euphoriant effect)
Inhibition of NMDA mediated glutaminergic transmission (amnesic effects)
64
How quickly does alcohol withdrawal syndrome occur
4-12 hours after the last drink
features being: coarse tremor, sweating, insomnia, tachycardia, nausea and vomiting, psychomotor agitation and generalised anxiety. Transitory visual hallucinations or auditory hallucinations may occasionally be present.
65
Describe the features of acute alcohol withdrawal
Course tremor, sweating, insomnia, tachycardia, nausea and vomiting, psychomotor agitation and generalised anxiety
Transitory visual hallucinations or auditory hallucinations may occasionally be present.
66
How often does delirium tremens occur within withdrawal
Occurs in about 5% of withdrawal causing Mortality in 5-10% cases.
67
Describe the features of delirium tremens
Clouding of consciousness, disorientation, amnesia, autonomic hyperactivity and hallucinations
hallucinations are tactile (often involving small people or animals, described as Lilliputian hallucinations)
68
What are Lilliputian hallucinations
A rare type of visual hallucination involving people or animals of small size.
Sometimes seen in delirium tremens
69
What features help to differentiate Wernick's encephalopathy and delirium tremens?
in Wernick's encephalopathy there is often loss of muscle coordination **ophthalmoparesis with nystagmus, ataxia, and confusion**.
In delirium tremens there are hallucinations and autonomic hyperactivity
70
Bipolar affective disorder requires at least how many episodes of mood disturbances?
1 episodes of mood disturbance, this can involve mania/hypomania, mania must last for 1 week
a depressive episode is not needed .
If patients have recurrent episodes of depression with no mania this would be diagnosed as a recurrent depressive disorder
71
Can psychotherapy be used in mania?
There is little efficacy for the use of psychotherapy such as CBT in active mania
72
What treatments can be used in the long-term management of acute mania
Atypical antipsychotics
lithium or valproate can be added or used as solo therapy if they have proved effective in the past.
73
SSRIs are generally not described for patients with a rapid cycling bipolar, what are the risks and in which circumstance can prescribe one
(bonus points for which SSRI)
In patients with a history of manic episodes caution is needed as a SSRI used to treat a depressive episode could trigger a subsequent manic episode.
Patient should only be prescribed SSRIs if they are taking an antipsychotic or antimanic agent, under the advice of the mental health team.
Fluoxetine is the only SSRI recommended by nice for use in bipolar
74
When can activated charcoal be used?
When a patient presents within the first hour of an overdose
1h
75
For a paracetamol overdose when should bloods be sent for aracetamol and Salicylate levels?
Peak plasma levels are reached after four hours after ingestion
4 hours to determine use of NAC
76
What is the most common type of dementia in UK
Alzheimer's disease
77
The onset of Alzheimer's disease is usually
(timeframe)
Gradual
78
Cholinesterase inhibitors can be used when in Alzheimer's disease
Mild-to-moderate stages
79
what Drug can be used in severe Alzheimer's
**memantine**
The principal mechanism of action of memantine is believed to be the **blockade of current flow through channels of N-methyl-d-aspartate (NMDA) receptors**--a glutamate receptor subfamily broadly involved in brain function.
80
What are the indications for **Memantine**
Moderate to severe Alzheimer's
(MS with Oscillopsia)
81
What is needed to be detained under a section 2
Assessment by two doctors, one of whom is approved under the mental health act, and an approved mental health professional usually a social worker
82
Defined delusion
A deeply held, unshakeable belief, out of keeping with social, cultural, religious and educational norms
83
Section 2 allows for a patient to be detained for how long?
28 days
specifically for assessment
84
Section 2 allows for a individual to be detained for what purpose
Assessment for up to 28 days
85
What section allows for detention up to 6 months for the purpose of treatment
Section 3
86
Section 3 allows for detention for how long and for what purpose
Up to 6 months where it can be renewed and is for treatment
87
Olanzapine is a good first choice treatment for acute psychosis why?
Nice recommends the usage of a atypical antipsychotic as first-line which olanzapine is it also has the benefit of having some tranquilization effect.
88
Increased appetite is a side effect important of which drug:
* olanzapine
* venlafaxine
* Lorazepam
* lithium
* chlorpromazine
Increased appetite is associated with olanzapine
89
Sedation is the primary Psych use of which drug:
* olanzapine
* venlafaxine
* Lorazepam
* lithium
* chlorpromazine
Sedation is associated with Lorazepam
90
Tremor is a side effect important of which drug:
* olanzapine
* venlafaxine
* Lorazepam
* lithium
* chlorpromazine
Tremor is associated with lithium
91
Tardive dyskinesia is a side effect important of which drug:
* olanzapine
* venlafaxine
* Lorazepam
* lithium
* chlorpromazine
Chlorpromazine is associated with tardive dyskinesia
92
Headache is a especially common side effect of which drug:
* olanzapine
* venlafaxine
* Lorazepam
* lithium
* chlorpromazine
Venlafaxine is fairly commonly associated headaches
93
A second person auditory hallucination as described as
A person commenting or talking directly to the patient, these could be in the form of commands
94
The MoCA is what
Montréal cognitive assessment, (a cognitive assessment tool)
95
The AMT is what
Abbreviated mental test, a good/quick screen for cognition
96
Profound learning difficulties are categorised as an IQ below?
20
97
Mild learning difficulties are defined as a IQ range between
50 and 69
98
Section 5.4 =
Nurses holding power (six hours)
99
Section 136 =
As used by police to take a patient from a public space to a place of safety
100
Risk assessment for mental health is not only for self-harm and suicide what other risks should be assessed for?
* Risk of worsening mental state
* risk of self neglect
* risk from others
* risks to property
* risk of disengagement from care
* risk of absconding
* risk to others
* risk to children
101
When assessing and managing risk what are the 4P's
1. Predisposing
2. precipitating
3. perpetuating
4. protective factors
102
Which three of these are atypical antipsychotics:
* risperidone
* aripiprazole
* chlorpromazine
* haloperidol
* olanzapine
* prochlorperazine
* Risperidone
* aripiprazole
* olanzapine
103
What are some examples of extrapyramidal side-effects:
* Tardive dyskinesia
* acute dystonia
* akathisia
* Parkinsonism
104
Patient taking third generation antipsychotics might experience parkinsonism symptoms, how might this present
Rigidity, bradykinesia, tremor
105
Akathisia is what
A subjective feeling of restlessness, this could be a extra pyramidal side effect
106
How might tardive dyskinesia present:
* Protrusion's/rolling of tongue
* smacking of lips
* during motion
* facial dyscinesia
* involuntary movement of body and extremities
107
Once a patient has been started on lithium how often should levels be monitored
ever 12 hours till theaputic window is met, then every five days till stable/ and five days after changing dose.
once stable every three months
108
What is an effective starting dose for olanzapine?
10 mg once daily
the BNF maximum is 20 mg daily
109
Who can apply a section 49
Ministry of Justice
110
What can the HCR 20 assessment tool be used for?
Assessment for risk of violence
HCR = historical, clinical, risk
there are 20 items
111
The PHQ-9 is the Patient Health Questionnair useful for what
A depression measurement tool
112
The PCL-R as a tool for measuring what
Psychopathic patients
| (psychopathic checklist (revised)
113
How can weight loss from depression be distinguished from anorexia nervosa
In weight loss due to depression there is low appetite, the **absence of a distorted body image** (mostly) and depressive symptoms
114
In anorexia nervosa what is the measure for low body weight
(roughly)
Below 85% of median weight for height/BMI below 17.5
115
What are the diagnostic features of anorexia nervosa besides low body weight?
* Deliberate measures to lose weight/keep a low (this includes dietary restrictions or excess calorie loss)
* morbid fear of fatness (this could be an overvaluation of the idea that they are larger than they are)
* endocrine dysfunction, this can manifest as amenorrhoea in women
116
Around what percentage of patients recover from anorexia nervosa (evidenced by a 20 year follow-up study)
Around 50% fully recover.
Around 15 % died from complications of anorexia
117
What reasons may require immediate or rapid admission for community patients with anorexia nervosa
(four)
1. Profound bradycardia (heart rate below 40)
2. Long QTc
3. refeeding syndrome
4. suicidal intent
118
Describe the cycle of bulimia nervosa
Reduced eating-intense hunger-out-of-control binge eating-guilt-purging
(purging may be via vomiting, excessive exercise, or medication like laxatives)
119
What is the defining difference between anorexia nervosa and bulimia nervosa
Kalemia patients do not reach the same weight loss.
A BMI below 17.5
120
What are the classical electrolyte and circulatory consequences of bulimia nervosa
* Hypokalaemia
* hypocalcaemia
* hypotension
* decreased red blood cell count
*
121
What is the mainstay of treatment for bulimia nervosa
* CBT, interpersonal therapy, cognitive behavioural self-help therapy
* antidepressants
*
122
From history how can one differentiate between vascular dementia and Alzheimer's disease?
Vascular dementia would be supported by a sudden onset, with a stepwise decline and history of vascular disease such as hypertension
123
How can dementia with Lewy bodies present
* Fluctuating cognitive impairment
* hallucinations (60% visual, auditory and 20%)
* features of parkinsonism
* comparatively sparing of short-term memory
*
124
In frontotemporal dementia what are some classical presenting features
1. Changes in interpersonal behaviour (including disinhibition)
2. apathy
3. blunting of emotions
4. language deficit
memory changes can occur but tend to be later
125
The gene APP (amyloid precursor protein) is implicated in what pathology?
Alzheimer's disease
it is located on chromosome 21 hence Alzheimer's disease is high in patients with Down syndrome
126
What are some poor prognostic factors for Alzheimer's disease
* Being male
* depression
* prominent behavioural problems
* severe focal cognitive deficits
127
Alzheimer’s is the most common form of dementia at what percentage?
60 to 70% of people suffering from dementia,
many people suffer from two forms of dementia however
128
Memantine
MOA and Use?
NMDA (glutamate) receptor partial agonist
severe dementia in Alzheimer's disease
129
Three ACh esterase inhibitor is normally used in early dementia
* **Donepezil**
* **Galantamine**
* **Rivastigmine**
130
What is Huntington's inheritance pattern
Autosomal dominant
131
What movement disorders Huntington's most strongly linked with
Chorea
132
**_Name that disease_**
low mood, memory problems, choreiform movements; and an autosomal dominant inheritance pattern.
Huntington's disease
133
Huntington’s disease is an autosomal dominant trinucleotide repeat disorder showing anticipation, what does this mean for subsequent generations
They are more likely to have more repeats and hence more likely to have earlier/more severe disease
134
In terms of medicating early psychosis what would be preferred
* high dose olanzapine
* low-dose aripiprazole
For early psychosis the mantra for medication is to “start low, go slow”.
Aripiprazole has fewer side effects than Olanzapine, in particular it is less likely to lead to weight gain.
135
In terms of medicating early psychosis what would be preferred
* high dose olanzapine
* low-dose aripiprazole
For early psychosis the mantra for medication is to “start low, go slow”.
Aripiprazole has fewer side effects than Olanzapine, in particular it is less likely to lead to weight gain.
136
Puerperal psychosis usually occurs in the first weeks post natal
Three
137
What are the preferred SSRIs to use during pregnancy
* Fluoxetine
* sertraline
* citalopram
* escitalopram
138
About 1 in 1000 babies exposed in first trimester to lithium have Ebstein’s Anomaly
what this be?
a serious cardiac anomaly
139
First trimester exposure to benzodiazepines is associated with an increased risk of
Cleft lip
140
Whilst thromboembolism remains the leading cause of maternal death during pregnancy and the 6 weeks postpartum, what is the most common cause of death during pregnancy and the postpartum year?
Suicide
141
Is lithium safe to use while breastfeeding
Lithium is contraindicated as it is found in high concentrations in breast milk
142
When differentiating between delusional thoughts and obsessional thoughts what is the key difference
(thinking about certainty)
Delusions patients are certain that their thoughts are true even when presented with evidence against and cannot be persuaded otherwise,
in obsessional thoughts patients can often describe the degree of uncertainty hence the need for obsessional checking. A part of them usually knows they do not need to be worried, which causes them distress.
143
What are some typical features of obsessional thoughts:
* They are usually resisted (as they are distressing to the sufferer)
* they often egodystonic (very different from the patient's normal beliefs)
* sexual content is not unusual
* they are intrusive and repetitive
*
144
What medical therapy is first-line for OCD
SSRIs
(they should be increased fairly quickly to maximum dose rather than waiting to see if lower doses take effect)
145
What is the only psychotherapy evidenced in OCD
CBT
146
What is the specific CBT used for OCD?
Exposure and response prevention (ERP)
patients are exposed to situations where they would normally carry out the compulsion, but must not conduct the compulsion.
This is much more effective against compulsions and obsessions.
147
What is one of the strongest risk factors for completed suicide
Previous self-harm (suicidal or non-suicidal)
148
In the appropriate population does lithium reduce suicide risk
yes
149
Benzodiazepines should be only used short-term in anxiety what duration is the maximum acceptable duration
Generally 2 to 4 weeks
150
What should be the reducing regime for someone who's taken long-term benzos
Reducing dose in steps of 1/8th of the daily dose every fortnight
151
What drug class is a GABA agonist
Benzodiazepine
152
What receptors do benzodiazepines affect
They potentiate the effects of GABA at GABA-A receptors
153
Which benzo has the shortest half-life and therefore the severest withdrawal
Lorazepam
154
For generalised anxiety disorder describe the first and second line pharmacological treatment
Initiate a SSRI first-line if this is unsuccessful after eight weeks trial a second SSRI
155
What is a treatment option for generalised anxiety disorder after two SSRIs have failed
Venlafaxine = SNRI
156
Venlafaxine is a?
SNRi
at high doses it can also act on dopamine reuptake
157
The first ranks symptoms of schizophrenia may also be seen in which condition
Mania
158
Patients who have an episode of mania are likely to go on to develop what
More than 90% of patients develop depression
159
A patient having an acute manic episode in the emergency department can be detained under which section?
Section 2 or 3
if this is the first episode section 2 is likely to be most appropriate this would require two doctors and an approved mental health professional
160
In an acute episode of mania is lithium used first-line
No
lithium is used as prophylaxis for mania/depression. Antipsychotics and benzos are generally used first-line for an acute mania
161
* Renal
* liver
* thyroid
* parathyroid
which of these do not need monitoring in patients being treated with lithium
Liver
lithium is renally excreted
162
While psychotherapy is useless in patients with acute mania where can it be useful in these patients
In patients with bipolar it can be used to help patients recognise relapse and improve their adherence with medication
163
According to the ICD 10 there must be at least two of these three symptoms to make a diagnosis of depression
* Low mood
* loss of interest
* lack of energy
164
An unpleasant sensation of restlessness (can be both subjective and objective) is called
Akathisia
165
Olfactory dyskinesia caused by antipsychotics =
Tardive dyskinesia
166
The main psychiatric use for sodium valproate is in what condition
Bipolar
167
Lithium and sodium valproate are both effective mood stabilisers in which population might lithium be optimal
Women of childbearing age
168
Flumazenil is used for what overdose?
Benzodiazepine and zopiclone
169
N-acetylcysteine is used for what overdose
Paracetamol
170
What is the treatment for a paracetamol overdose
N-acetylcysteine **(NAC)**
171
What is the eponymous new natal cardiac syndrome associated with lithium
Ebstein Anomaly
172
What is Ebstein's anomaly
The displacement of the neonatal tricuspid valve, seen in lithium used during pregnancy
173
Lithium toxicity occurs at plasma levels above 1.5 mmol per litre what are some symptoms
* Course tremor
* polydipsia and polyuria
* vomiting
* delirium
174
What endocrine system is lithium known for affecting?
Thyroid
often causes hypothyroidism in need of treatment with levothyroxine
it can also sometimes cause hyperthyroidism however this is a common
175
Describe the initial treatment algorithm for a patient diagnosed with mild depression
Further assessment should be arranged, usually a two-week period of watchful waiting.
Guided self help and short-term psychological treatment should be considered
176
List some medications that may cause/exacerbate depression:
* Antihypertensives (e.g. beta-blocker's)
* corticosteroids
* oral contraceptives
* ranitidine
* statins
177
Antidepressants should be continued for six months after remission of symptoms in the first instance, how long should they be continued for for a second episode of depression
Two years is recommended
178
This serotonin syndrome is a potential risk of any medication that enhances serotonergic transmission, what are some of its symptoms:
* Cognitive = confusion, headaches
* autonomic symptoms = sweating, hypothermia, tachycardia
* neurological symptoms = myoclonus and hyperreflexia
179
The patient with a history of depression presents in a confused state, complaining of headaches.
They are sweating and tachycardic with brisk reflexes and a high temperature.
What is an important differential?
Serotonin syndrome
180
What class of drug is venlafaxine
Serotonin and noradrenaline reuptake inhibitor = SNRI
181
What class of drug is duloxetine
Noradrenaline and specific serotonin antidepressant
NaSSA
182
What class of drug is mirtazapine
Noradrenaline and specific serotonin antidepressant
NaSSA
183
Escitalopram =
SSRI
184
What are some common side effects of amitriptyline
* Dry mouth
* sedation
* blurred vision
* constipation
* postural hypotension
185
What are some rare significant side effects of amitriptyline
* Convulsions
* urinary symptoms
* cardiac dysrhythmia
* hyponatraemia
* hepatic impairment
186
What cardiac condition is an especially important contraindication to amitriptyline
(immediately post-myocardial infarction and cardiac arrhythmias are general contra-indications)
Complete heart block
187
Tricyclics (and SSRIs) should never be taken in combination with MAOIs due to risk of what?
Serotonin syndrome
188
When amitriptyline is taken alongside beta-blockers there is a increased risk of what?
Ventricular arrhythmias
189
What are some physical signs of benzodiazepine withdrawal
Patient presented as tremulous, ataxic, hyperreflexia
* * Hypothermia
* tachycardia
* tachypnoea
* hypertension progressing to hypotension
* palpitations
patient can also exhibit muscle spasms and rhabdomyolysis
190
What over-the-counter/nonprescription drug is important to consider as a cause of lithium toxicity
Nonsteroidal anti-inflammatory is as they can reduce excretion
191
What long-term effect can lithium have on the kidneys
(treatment for around 15 years)
Irreversible nephrogenic diabetes insipidus
192
Once a patient is unstable lithium treatment how often should they have their levels checked? And how often should they have their thyroid function checked
* Three months for lithium levels
* six months for thyroid function
193
Hair loss with curly regrowth, weight gain and nausea are side effects of?
Sodium valproate
194
In patients who suffer with recurrent depression nice recommend what duration of SSRI treatment
Two years minimum
195
How can SSRI discontinuation syndrome present??
Flulike symptoms
dizziness
insomnia
nausea and vomiting
sweating
agitation
electric shock sensation
tinnitus and headaches
196
What GI symptoms are SSRIs known to cause
* Dyspepsia
* nausea
* vomiting
* diarrhoea
* constipation
197
What can SSRIs do to your sodium
Hyponatraemia
198
What drug class is mirtazapine
Noradrenaline and specific serotonin antidepressant
199
What drug class is reboxetine
Selective noradrenaline reuptake inhibitor
200
What drug class is trazodone
Tricyclic related antidepressant
201
What drug class is moclobemide
Reversible monoamine oxidase inhibitor
202
What drug class is duloxetine
Serotonin and noradrenaline reuptake inhibitor
203
What drug class is venlafaxine
Serotonin and noradrenaline reuptake inhibitor
204
Electroconvulsive therapy is recommended when
A person suffering from severe life-threatening depressive illness, catatonia, prolonged or severe manic state
205
What are some known side-effects of ECT
* Amnesia (anterior grade or retrograde)
* headaches
* muscle pains
* many more I imagine
206
What is the strongest risk factor for developing a psychotic disorder
**_Family history_**
Risk of developing schizophrenia
* monozygotic twin has schizophrenia = 50%
* parent has schizophrenia = 10-15%
* sibling has schizophrenia = 10%
* no relatives with schizophrenia = 1%
207
Describe the difference between hypochondrial disorder and somatisation disorder?
Somatisation disorder is the complaint of persistent unexplained symptoms rather than a fear of a diagnosis
Unexplained symptoms
* **S**omatisation = **S**ymptoms
* hypo**C**hondria = **C**ancer
208
Somatisation disorder would present as?
Patient complaining of multiple physical symptoms for at least two years, and where the patient refuses to accept reassurance or negative test results
209
Describe the presentation of illness anxiety disorder or hypochondriasis
* The persistent belief in the presence of an underlying serious disease such as cancer
* the patient refuses to accept reassurance or negative test results
210
Describe fictitious disorder
Also known as Munchausen, it is the intentional production of physical or psychological symptoms
211
Emotionally unstable personality disorder
(sometimes called borderline personality disorder)
classically has these features
* Unstable interpersonal relationships that alternate between idolisation and devaluation
* Emotional instability displayed as mood swings
* unstable sexual relationships
* anger
* affective disorders
* often history of self-harm
212
Amitriptyline has anticholinergic effects, these include:
* Tachycardia
* dry mouth
* mydriasis
* urinary retention
also includes constipation and lengthening of QT interval
213
What are the main criteria to differentiate between mania and hypomania
* Mania tends to have a prolonged time course (hypomania often last less than 10 days)
* mania exhibit psychotic symptoms
patients with hypomania are often able to maintain some functional capabilities this is often not the case with mania
214
What is an absolute contraindication to electroconvulsive therapy
Raised ICP
215
Briefly describe the pathology that leads to seizures in alcohol withdrawal
Long-term alcohol use leads to an up-regulation of glutamate receptors (excitatory) and a down-regulation of GABA receptors.
If patient stopped drinking suddenly there is an excess of excitatory action leading to symptoms of an overactive synthetic nervous system.
This dysregulation can lead to seizures, and the symptoms are present with withdrawal such as restlessness, being sweaty and tremulous+ agitation
216
Why is chlordiazepoxide used over Lorazepam in a patient undergoing alcohol withdrawal
It has a longer half-life and therefore gives seizure protection for longer without continuous dosing
217
After changing the dose of a patient's lithium when should you check lithium levels
Weekly until levels are stable
218
What does the simple screening tool for depression include?
During the last month have you often been feeling down, depressed or hopeless?
During last month have you often been bothered by having little interest or pleasure in doing things?
219
Depression diagnosis and some rating scales include:
* Simple screening
* patient health questionnaire (PHQ-9)
* hospital anxiety and depression scale (HAD)
* Beck depression inventory second edition (BDI-II)
*
220
What are some symptoms of hypothyroidism that may help to differentiate it from depression include:
* Cold intolerance
* weight gain
* constipation
* hair loss
* bradycardia
221
# Thought (blank)
A patient complaining of losing her train of thought often, which she believes is the result of the government stealing her thoughts as an example of
Thought withdrawal
222
# Long acting benzodiazepine
First-line treatment in acute alcohol withdrawal with features of tremor, sweating, tachycardia and anxiety
Chlordiazepoxide
223
When is the peak incidence of seizures in acute alcohol withdrawal
36 hours
224
# Pharmaceutical
In severe OCD or OCD unresponsive to CBT and exposure and response prevention therapy what can be added
An SSRI-sertraline
225
What is the SSRI of choice in patients that have had a recent MI or have unstable angina
Sertraline
226
Define the difference between obsession and compulsion
An **obsession** is an intrusive, unpleasant and unwanted thought
a **compulsion** is a senseless action taken to reduce anxiety caused by the obsession
227
Acute dystonia secondary to antipsychotics is usually managed with
Procyclidine
an anticholinergic, This helps decrease muscle stiffness, sweating, and the production of saliva, and helps improve walking ability in people with Parkinson's disease.
228
When stopping long-term SSRIs what time period Should the dose be reduced over
Four weeks
229
Discontinuation syndrome of SSRIs include symptoms of:
* increased mood change
* restlessness
* difficulty sleeping
* unsteadiness
* sweating
* gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
* paraesthesia
