Charlie Rookes Psychiatry EMQs from PRN online Flashcards

Question

``` A. Manic episode B. Cyclothymia C. Schizoaffective disorder D. Delirium E. Bipolar affective disorder F. Schizophrenia G. Depressive episode H. Pseudodementia ``` Labile mood, boundless energy, reduced sleep. No previous history of mood disorder.

Answer 1

A. Manic episode

Answer 2

G. Electroconvulsive therapy (ECT) ECT can be life-saving in severe depression, since it is a very fast and effective treatment.

Answer 3

C. Supportive counselling Supportive counselling is often sufficient, though mildly depressed patients should still be reviewed to ensure that they are not deteriorating, despite the counselling.

Answer 4

B. Cognitive behavioural therapy and antidepressant This combination is the ideal, though be aware that CBT waiting lists can be long (e.g. 6 months), so this is not always achievable.

Answer 5

A. Antidepressant and antipsychotic Both are required to effectively treat the two aspects of this diagnosis: psychosis and depression.

Answer 6

E. Mood stabiliser or antipsychotic Addictionally, antidepressants and other exacerbating medications should be stopped. A short course of benzodiazepines may be additionally needed for sedation. Is symptoms are severe or don't respond to a mood stabiliser or antipsychotic alone, they may need to be combined.

Answer 7

C. Amnesia Most other side effects from ECT relate to use of the general anaesthetic (e.g. risk of death).

Answer 8

B. Hypertensive crisis following ingestion of yeast extracts Other side effects of MAOIs include hypotension, dizziness, drowsiness, insomnia, headache, blurred vision, constipation, nausea and vomiting.

Answer 9

A. Unreliable oral contraceptive pill cover St John's Wort is an enzyme inducer, causing some drugs (like the OCP) to be metabolised more quickly, making them ineffective.

Answer 10

G. Foetal Ebstein's anomaly This is a risk when lihium is used during pregnancy. Ebstein anomaly is a congenital malformation of the heart that is characterized by apical displacement of the septal and posterior tricuspid valve leaflets, leading to atrialization of the right ventricle with a variable degree of malformation and displacement of the anterior leaflet.

Answer 11

E. Foetal spina bifida This is a risk when sodium valproate (or carbamazapine) is used during pregnancy.

Answer 12

G. 4-6 weeks

Answer 13

B. 2 hours

Answer 14

I. 8-9 months

Answer 15

H. 6 months

Answer 16

G. Cognitive behavioural therapy (CBT) Negative Automatic Thoughts (NATs) are the unhelpful, negative thoughts, typical of depression, that pop into a person's mind as a knee-jerk reaction to everyday situations. They are often overly pessimistic or critical, and contribute to low mood and further depressive thoughts, which trap the person in their depression. E.g. in response to someone not greeting them at work, a depressed person may think, "He hates me" or "No-one likes me." These are identified in CBT and the patient works with the therapist to consider how true they really are. Logic and practical testing of NATs can usually show that they are at some level erroneous. The patient is helped to recognise these NATs, recognise underlying thinking errors and think more positively and realistically, in order to combat depression.

Answer 17

H. Psychodynamic psychotherapy Transference describes the emotions that a patient feels towards the therapist. It can be used to interpret the patient's problems, and help the patient to think about relationships outside the therapy session - since it usually sheds light on the way they view other people and interact with them.

Answer 18

G. Cognitive behavioural therapy (CBT) Behavioural experiments are practical and logical tests, which help patients do as "homework" in their own time, to test out their beliefs.

Answer 19

H. Psychodynamic psychotherapy The relationship that is built in the session gives insight into the relationships and relationship difficulties outside the therapy.

Answer 20

C. Interpersonal therapy (IPT)

Answer 21

B. Schizophrenia Schizophrenia is the most likely diagnosis, in view of ongoing (>1 month) symptoms, in the absence of ongoing drug misuse. The symptom of thought withdrawal is not diagnostic in its own right (first rank symptoms can occur in other disorders, e.g. organic), but again supports the diagnosis of schizophrenia.

Answer 22

I. Depression Depression is the most likely diagnosis, since this man has core and biological features sufficient to make the diagnosis, and symptoms have been ongoing for greater than two weeks. The recent alcohol misuse does not amount to alcohol dependence, and this is supported by the normal blood results.

Answer 23

Personality disorder is the most likely diagnosis, though note that, even with a clear history of personality difficulties, this diagnosis is not always reliable after a single interview, and the diagnostic label can be stigmatising rather than helpful. That stated, there is evidence from the history that this man's personality has caused him chronic difficulties (e.g. impulsivity and outbursts of anger; ongoing affective instability). With closer questioning, it should be possible to elicit elements such as ongoing fears of abandonment or intense and unstable relationships, etc - sufficient to decide whether he fulfils criteria for emotionally unstable personality disorder.

Answer 24

C. Drug induced psychosis A drug induced psychosis is the most likely diagnosis, due to the temporal relationship between the use of cocaine and onset of psychotic symptoms, as well as the fact that this symptom (formication) being well-recognised in cocaine use. Symptoms should resolve with cessation of coke use. Although her pattern of alcohol use does not suggest dependency, and the clinical picture is more suggestive of coke intoxication than alcohol withdrawal/ delirium tremens. She should be given advice on her harmful levels of alcohol use, as well as the dangers of cocaine - but this is best done once she is medically fit, and once the cockroaches have stopped running about under her skin...

Answer 25

F. Bipolar affective disorder Bipolar affective disorder is the preferred diagnosis, in view of a previous affective episode (depression) - this can no longer be viewed as a single manic episode.

Answer 26

H. Discharge with a Community Mental Health Team visit within the next 48 hours More information is needed before making a final decision, but the family's plan sounds both safe and practical. The Community Mental Health Team may have a Home Treatment Team, who should be contacted to try and arrange a visit as soon as possible, but certainly within the week. When discharging someone home, always make sure that they know to attend casualty for review if they feel their situation is worsening.

Answer 27

I. Give N-acetylcysteine A graph of plasma paracetamol concentrations against time should be used clinically to assess whether paracetamol levels require treatment with N-acetylcysteine. For most patients, the levels need to be above the normal treatment line before they require treatment. A second line shows lower levels of plasma paracetamol concentrations for assessment of "high-risk" patients, who are at risk of liver damage from lower levels of paracetamol. High risk includes those who are malnourished (e.g. in anorexia, alcohol dependency), or using enzyme inducing drugs (e.g. phenytoin, St. John's wort, carbamazepine). Once she has been medically cleared, you can further assess her and make a decision about her future management, e.g. admission / discharge / follow-up plans.

Answer 28

F. Mental Health Act assessment This woman is at high risk of suicide, and she will probably require admission for her own safety and a full assessment of her mental state. Her refusal of admission leaves you no choice other than to organise a Mental Health Act assessment, and she should not leave hospital until this has been carried out. Accidental overdoses do happen (not everyone is suicidal!) but this woman's circumstances should raise your suspicion that she will not be alive in a week's time for an outpatient appointment.

Answer 29

A. Informal admission to a psychiatric ward It would be a very brave / foolhardy doctor who would send this woman home to an empty house, even with Community Mental Health Team input. Though her parents are willing to maintain telephone contact with their daughter, this really doesn't provide the level of monitoring and support needed to feel that she is safe by herself, and her suicidal behaviour happened when they were out (presumably at work) today. She appears willing to come into hospital voluntarily, and no matter how severe her mental illness, there is no need for a Mental Health Act assessment to enable this.

Answer 30

F. Mental Health Act assessment A Section 5(2) may be required to prevent this man leaving the ward until a formal Mental Health Act Assessment can be arranged to consider him for a Section 2 or 3.

Answer 31

E. Delusional perception This is an example of delusional perception: a two-stage process whereby a real perception is then interpreted in a delusional way. It is classified as a primary delusion (i.e. arising "out of the blue" and not preceded by prior symptoms of mental illness like hallucinations) - and as such, is relatively rare. If the example given was in the context of pre-existing mental health symptoms (i.e. not the first symptom of something "going on"), it would be classed as a delusion of reference.

Answer 32

I. Passivity Passivity phenomena are delusional beliefs that movement, sensation, emotion or impulse are controlled by an outside force. In this example, a real or hallucinatory sensation (pain) is attributed to the deliberate control of another person.

Answer 33

D. Thought echo In thought echo, the patient's thoughts are said aloud. This is not the same as the normal experience of "thinking in your head". There are two types: Gedankenlautwerden is when the thought and voice occur together; echo de la pensées is when the voice comes immediately after the thought.

Answer 34

G. Third person auditory hallucinations Third person auditory hallucinations are voices talking about the person. Voices discussing or arguing about the patient, as in this example, are classed as first rank symptoms.

Answer 35

F. Thought broadcasting Thought broadcasting is the delusional belief that thoughts are not contained privately in the person's head, but somehow broadcast to other people so that people know what they are thinking.

Answer 36

B. Risperidone Risperidone is the only atypical antipsychotic available as a long-acting injection (depot), and in this form can be given once a fortnight. Depot medications are used when people find daily medication concordance problematic.

Answer 37

G. Clozapine Clozapine was withdrawn for some years due to the risk of agranulocytosis and death. It was only reintroduced with strict monitoring of the white cell count, in order to pick up early signs of neutropenia. All patients in the UK must be registered with a clozapine monitoring agency, before they can start clozapine.

Answer 38

I. Chlorpromazine

Answer 39

A. Procyclidine Procyclidine is an anticholinergic drug, and effective treatment for acute dystonias (painful muscle spasms, e.g. torticollis). IM injection may be needed where a fast treatment is required, or where the patient's ability to swallow safely is compromised by the spasms.

Answer 40

G. Clozapine Clozapine is the only antipsychotic with proven efficacy in schizophrenia that has been shown to be resistant to other antipsychotics. In the UK, the NICE guidelines advise that it is used when a patient has failed to respond to two antipsychotics - one of which should be an atypical - given at therapeutic doses for at least 6 weeks each.

Answer 41

F. Naloxone Naloxone is an opiate antagonist, and is the antidote for opiate overdoses. It works very quickly, and plunges patients into immediate withdrawal. Once injected, be ready to stand back - patients tend not to be very happy about being "saved" from their euphoric near-death experience, and are unsurprisingly a little angry when they wake up...

Answer 42

G. N-acetyl cysteine

Answer 43

D. Rehydration One of the complications of ecstasy use is dehydration, and this should be reversed to prevent further complications.

Answer 44

B. Chlordiazepoxide and thiamine Chlordiazepoxide is a long-acting benzodiazepine that replaces alcohol at receptor level to prevent withdrawal symptoms. It can be gradually withdrawn and stopped. Thiamine is prescribed as prophylaxis against Wernicke's encephalopathy.

Answer 45

A. Flumazenil Flumazenil is a benzodiazepine antagonist, and thus the antidote to benzodiazepine overdose.

Answer 46

G. Codeine Codeine and other opiate (e.g. heroin) produce a pleasant feeling of euphoria, warmth and well-being, along with sedation and anaesthesia. The side effects include nausea and vomiting, bradycardia and respiratory depression. Death can result from respiratory failure or aspiration of vomit.

Answer 47

B. Cannabis The effects of cannabis vary with expectation and mood before use: paranoia, euphoria and anxiety are all common. Hunger is sometimes called "the munchies" and people tend to want to eat sweet foods.

Answer 48

H. Solvents Solvents produce a "drunken" feeling, with euphoria, disinhibition, ataxia, nausea, vomiting, dizziness, hallucinations and confusion, at differing levels. Coma can occur, and can cuase death if vomit is aspirated.

Answer 49

A. Ketamine Ketamine is a member of the hallucinogens, which cause hallucinations, visual distortions and synaethesia (the experience of one perception in another modality). Due to its anaesthetic properties, people can cause themselves great harm while under its influence. Other drugs in this group include LSD, PCP and magic mushrooms.

Answer 50

C. Ecstasy Ecstasy is a cross between a stimulant and a hallucinogen. Users get a sense of enhanced empathy, and increased energy - users appear excessively friendly, and energetic. Side effects include nausea, vomiting, sweating, dehydration and death.

Answer 51

This is relapse: falling back into use after an attempt at abstinence.

Answer 52

H. Maintenance Maintenance is when someone is able to maintain abstinence (or safe usage).

Answer 53

H. Maintenance Maintenance is when someone is able to maintain abstinence (or safe usage).

Answer 54

A. Pre-Contemplation Pre-contemplation is when the person doesn't see or a problem, or doesn't have any intention to change their usage.

Answer 55

E. Preparation Preparation is when the person is willing to change, and is planning to do this soon.

Answer 56

C. Skinnerian conditioning Skinnerian (or operant) conditioning depends on repetitive behaviours having predictable outcomes. Positive conditioning is when behaviours that are rewarded are repeated.

Answer 57

F. Social learning theory Social learning theory (or vicarious learning) is the idea that we learn by copying the behaviours of those around us.

Answer 58

G. Pavlovian conditioning Pavlovian (or classical) conditioning occurs in substance misuse when cravings become conditioned to cues, such as walking past a pub.

Answer 59

A. Neurobiological theories Neurobiological theories of substance misuse focus on the way that drugs affect dopamingeric "reward" pathways in the brain.

Answer 60

C. Skinnerian conditioning Skinnerian (or operant) conditioning depends on repetitive behaviours having predictable outcomes. Negative conditioning is when behaviours are repeated if they relieve an unpleasant experience.

Answer 61

C. Parietal Lobe Damage to the parietal lobe can cause apraxia - the inability to carry out skilled tasks despite intact sensory and motor function. The example giving is of dressing apraxia.

Answer 62

A. Frontal Lobe This is a Broca's dysphasia, whereby expression of speech is poor, but comprehension is normal. Broca's area lies within the left frontal lobe in right-handed people and the majority of left-handed people.

Answer 63

A. Frontal Lobe This is suggestive of frontal lobe damage, though a more generalised delirium state should be excluded first.

Answer 64

D. Occipital Lobe The primary visual cortex lies within the occipital lobe. Damage here can cause visual disturbances.

Answer 65

B. Temporal Lobe This is strongly suggestive of temporal lobe epilepsy.

Answer 66

E. Multiple sclerosis Multiple sclerosis may run a relapsing and remitting course. Mood changes such as lability, depression and mania are relatively common, and may relate to the disease itself or to the medication used to treat it.

Answer 67

M. Epilepsy Epilepsy is associated with a fourfold increased risk of suicide, and up to 50% of patients suffer from depression at some point in their illness. See page 127.

Answer 68

K. Medication side effect Medications can cause numerous side effects, and in this case, the most likely scenario is that the woman's colitis has been successfully treated with steroids, and these have triggered a hypomanic / manic presentation.

Answer 69

A. Amnesic syndrome In amnesic (or "amnestic") syndrome, there is a profound anterograde memory loss: the patient cannot lay down new memories. Other aspects of their memory and overall cognition are relatively intact.

Answer 70

D. Post-concussional syndrome Post-concussional syndrome occurs in up to 50% of people who have suffered a mild head injury with loss of consciousness. Mood, cognitive and somatic symptoms may present, and the patient is usually preoccupied with these symptoms.

Answer 71

E. Creutzfeldt-Jakob disease This is a florid plaque from the brain of a patient with variant Creutzfeldt-Jakob disease. It is not a common disease in old age, but should be considered in patients with early onset dementias.

Answer 72

J. Alzheimer's Disease This is a plaque from the brain of a patient with Alzheimer's disease.

Answer 73

I. Dementia with Lewy bodies

Answer 74

D. Huntington's disease

Answer 75

C. Frontotemporal lobar degeneration Frontotemporal lobar degeneration is an umbrella term for a number of disorders united by asymmetrical frontal and / or anterior temporal lobe atrophy. The picture shows Pick bodies, seen in the Pick's disease subtype. These dementias tend to affect younger patients (under 60).

Answer 76

D. Minimise cardiovascular risk factors On the basis of this history, vascular dementia is a concern, though delirium must be excluded first. Whatever the diagnosis, this gentleman needs to minimise his cardiovascular risk factors by addressing his smoking, concordance and diabetic management.

Answer 77

H. Levothyroxine The slowed thoughts and movements, lethargy and weight gain could all suggest depression, but in the context of her medical history, hypothyroidism should be excluded, since the thyroid gland may have been damaged by radiotherapy. If her TFTs are normal, depression would be the next diagnosis to consider.

Answer 78

C. Sertraline This is depression, presenting as "pseudodementia".

Answer 79

E. Donepezil This is likely to be Dementia with Lewy Bodies (suggested by new parkinsonian signs, vivid visual hallucinations). Acetylcholinesterase inhibitors are used in both DLB and Alzheimer's disease.

Answer 80

B. Cognitive behavioural therapy This is agoraphobia with panic attacks. Cognitive Behavioural Therapy would incorporate exposure therapy and thought diaries to improve this woman's ability to cope with crowded places. Avoidance would be unhelpful.

Answer 81

F) OCD Obsessive Compulsive Disorder is characterised by obsessions (in this case, images of sex acts) and compulsions (in this case, the "special prayer").

Answer 82

H) Panic disorder Maria is suffering from panic attacks, and the pattern of several attacks within a month raises the diagnosis to that of panic disorder.

Answer 83

C) Social phobia This is a typical presentation of social phobia, where situations are avoided if they could give rise to embarrassment or to scrutiny by others. Lauren's problems appear limited to these situations, since she clearly copes well with large crowds of people (someone with agoraphobia would have difficulties with music festivals) and doesn't appear to have an anxious personality (hang-gliding is generally not for the faint-hearted!). Alcohol misuse is common.

Answer 84

B) Agoraphobia Agoraphobia has the potential to cause extreme disability, since people can become completely housebound.

Answer 85

A) GAD The fears in generalised anxiety disorder (GAD) are non-specific and the anxiety is "free-floating". Physical anxiety symptoms (such as tension headaches) are prominent.

Answer 86

E) Benign essential tremor This can be confused with Parkinson's Disease (PD). Essential tremors are intention tremors and often begin in the hands but can progress to affect the head and voice. In PD, tremors occur at rest and typically affect the hands.

Answer 87

F) Parkinsonism This gentleman has signs of parkinsonism. He has a resting tremor, voice changes and "mask like" facies. It may be Parkinson's disease, or secondary to other causes (e.g. extrapyramidal side effects from antipsychotic medications).

Answer 88

A) Phaeochromocytoma In phaeochromocytoma, symptoms mimic those of extreme anxiety and are episodic in nature. Tumours are commonly benign and symptoms will resolve with surgery.

Answer 89

G) Alcohol withdrawal The inability to drink alcohol while on his flight causes withdrawal symptoms only towards the end of the flight; Roger can access alcohol in the hotels - which causes his symptoms to cease.

Answer 90

B) Hyperthyroidism Hyperparathyroidism causes raised calcium levels, and problems such as fractures (osteoporosis), renal stones, abdominal pain, low mood: "Bones, stones, groans and psychic moans." Increased thirst is an associated symptom.

Answer 91

E. CT Head The presentation is of a stroke, and no amount of historical medically unexplained symptoms should prevent investigation and treatment in this man's case! It is likely that his "similar symptoms" represented a transient ischaemic attack.

Answer 92

G. CBT Cognitive Behavioural Therapy is of proven benefit in Chronic Fatigue Syndrome.

Answer 93

C. Encourage reattribution of symptoms to non-organic cause She has been fully investigated and you would be likely to cause further distress and harm by ordering further investigations (as well as annoying your specialist colleagues!). Unresolved stressors and grief issues need to be explored with this woman.

Answer 94

D. Reassure symptoms will resolve quickly This is a fairly clear-cut case of conversion aphonia. The acute onset, combined with a recent stressor and "belle indifference" (lack of concern) are the important clues. Reassurance that symptoms will pass soon will help the prognosis, and this man should be encouraged to seek support for his marital problems. Reattribution of symptoms may be tricky in an acute situation like this, but can be tried. The most important thing is to ensure that his symptoms are not reinforced by the acceptance of disability.

Answer 95

I. Diazepam A history of "pseudoseizures" does not exclude "organic" seizures, and there is an increased risk of pseudoseizures in people with epilepsy. The history of incontinence and accidental injury are not diagnostic of either type of seizure, but would be more unusual in a pseudoseizure. Insertion of an oropharyngeal airway is not impossible in a pseudoseizure, but would be very unusual (NB: it should not be used as a diagnostic "tool").

Answer 96

H. Malingering Malingering is the deliberate production of symptoms to gain external rewards.This presentation is not diagnostic, since the man may have many reasons behaving in this way, but it should alert you to the possibility that he is feigning symptoms to obtain a reward other than the sick role itself - in this case, the reward is opiates.

Answer 97

C. Factitious disorder Please note that the diagnosis of factitious disorder in this woman should not prevent treatment (after a capacity assessment, if the patient refuses treatment), i.e. Vitamin K. Her immediate medical problems must be dealt with, whatever the cause. The concern that she is causing herself to bleed should be discussed with her openly, and a psychiatric referral made. Don't forget to consider the impact on her husband, who may be under-warfarinised as a result of her use of his tablets. This presentation is sometimes called Munchausen's syndrome.

Answer 98

F. Hypochondriasis Hypochondriasis is an extreme form of health anxiety, whereby the patient believes that they have a specific illness (e.g. a brain tumour) rather than simply presenting with inexplicable symptoms.

Answer 99

E. Somatization disorder In somatization disorder, there are multiple medically unexplained symptoms, affecting different systems of the body.

Answer 100

G. Delusional disorder This particular delusion of infestation, in the absence of any other psychiatric symptoms or systematised delusions, is known as Ekbom's syndrome.