Corrections Flashcards
What is likely to be seen on a CT scan in normal pressure hydrocephalus?
Enlarged ventricles and ABSENT sulci
CJD is caused by which infective organism or molecule?
Prion
What is a prion?
Misfolded proteins that induce other proteins to misfold.
This causes neurones to die, leaving holes in the brain tissue.
This leads to a sponge-like appearance (spongiform encephalopathy)
What is a likely side effect of memantine?
Constipation
A 72-year-old woman is assessed in memory clinic after her partner noticed she was more forgetful. Around twelve months ago, she seemed to suddenly become quite forgetful. Roughly six months after this, her memory seemed to deteriorate further and has since remained at this level. She has no past medical history aside from hypercholesterolaemia and osteoarthritis of the knee.
What is an appropriate pharmacological management of this patient’s memory loss?
Patient has vascular dementia. AChIs are NOT indicated in vascular dementia.
Patient has hypercholesterolaemia –> can prescribe a statin to address CVS risk factors.
For how long can a patient be legally detained under section 5(2) of the MHA?
72 hours
Why can AChEIs not be prescribed in patients with QT prolongation?
These drugs can cause QT prolongation and could theoretically be dangerous in some patients with LQTS.
Contraindications of AChEIs?
- QT prolongation
- 2nd/3rd degree heart block in an unpaced patient
- Sinus bradycadia <50 bpm
What is an alternative to AChEIs in patients with dementia with a contraindication e.g. QT prolongation?
Cognitive stimulation therapy
What is the most appropriate treatment for patients with SEVERE Alzheimer’s?
Memantine
What section of the Mental Health Act 1983 can be used to detain patients for up to 6 months for treatment?
3
What is section 4 of the MHA?
Designed for emergencies when applying Section 2 would cause an unnecessary delay.
Requires the recommendation of a single doctor and the involvement of either an AMHP or the nearest relative.
The patient can be detained for a maximum of 72 hours, typically followed by a transition to Section 2.
What are the side effects of AChEIs?
Cholinergic side effects (due to increase ACh) e.g. diarrhoea, N&V, braydcardia, increased salivary production, and urinary incontinence
What is semantic memory?
Ability to associate meaning to objects present via visual or auditory modalities
What is semantinc dementia a type of ?
FTD
What is FTD also known as?
Pick’s disease
Why are those with Down’s syndrome more likely to get early onset Alzheimer’s?
The exta copy of APP can lead to early onset beta amyloid plaques
What is the definitive diagnostic test for CJD?
Tissue biopsy - via brain biopsy or at post-mortem
Which dementia subtype is the use of haloperidol contraindicated in?
Dementia with Lewy bodies –> these patients are highly sensitive to neuroleptics which can cause a deterioration in parkinsonism
Which antipsychotic is most likely to cause neutropenia?
Clozapine
What neutrophil count should lead to the discontinuation of clozapine?
<0.5
Symptoms of neutropenia?
A fever, which is a temperature of 100.5°F (38°C) or higher (symptoms of infection)
Chills or sweating.
Sore throat, sores in the mouth, or a toothache.
Abdominal pain.
Pain near the anus.
Pain or burning when urinating, or urinating often.
Diarrhea or sores around the anus.
A cough or shortness of breath.
What blood test is needed to assess white blood cells?
FBC
What other side effects is akathisia associated with?
Due to distressing nature:
- Aggression
- Low mood
- Suicidal ideations
What is neuroleptic malignant syndrome (NMS)?
A rare but life-threatening reaction to antipsychotics
Symptoms of NMS?
Sweating, fever, rigidity, confusion, fluctuating consciousness, fluctuating BP, tachycardia
What blood test is needed in NMS?
Creatinine kinase
Effect of NMS on creatinine kinase? Why?
Raised creatinine kinase
As NMS invovles the breakdown of muscle tissue
What is alogia?
Paucity of speech (a common negative symptom of schizophrenia)
What is the 1st line treatment for paranoid schizophrenia?
Atypical antipsychotics e.g. risperidone
Symptoms of clozapine toxicity?
Confusion, drowsiness, ataxia, tachycardia
What can clozapine toxicity be precipitated by? Why?
Acute infection e.g. pneumonia
Clozapine is metabolised by P450 system –> downregulation of these enzymes during infection/inflammation can lead to increased clozapine level
Which specific ECG change can be associated with haloperidol use?
QT interval prolongation
A 35 year old woman with schizophrenia is clerked by the on-call psychiatrist.
In the conversation, he asks her about her upcoming plans. She replies “I thought I’d take a trip to London but I was worried about the tube, smarties often come in tubes and they’re my favourite sweet, I’ve been trying to cut down on sweets to be healthier, I’d like to lose some weight before my trip, I’ve decided to take a trip to Brighton next week”.
What aspect of formal thought disorder is this patient displaying?
Circumstantiality
What is circumstantiality?
Moving on to different topics but there is a train of thought that can be followed
Eventually return to original question
What is thought blocking?
Patient suddenly halts in their thought process and cannot continue e.g. abrupt silence
Which antipsychotic has a much lower risk of inducing hyperprolactinaemia?
Aripiprazole
What class of drug is procyclidine?
Anticholinergic
When is schizophrenia deemed ‘treatment resistant’?
Not responded to sequential treatment with TWO DIFFERENT antipsychotics
What electrolyte abnormality is most likely to be found in blood tests following a panic attack?
Why?
Hypocalcaemia
A sudden feeling of intense anxiety can cause hyperventilation –> this REDUCES arterial CO2 and INCREASES blood pH (alkalosis)
Alkalosis promotes calcium binding to albumin –> reduces levels of free calcium –> hypocalcaemia
What are some symptoms of hypocalcaemia?
Tingling or numbness in hands, feet or around mouth
How do obsessive compulsive disorder and obsessive compulsive PERSONALITY disorder differ?
Both feature a preoccupation with rules, details, and organisation to the detriment of other aspects of their life.
BUT, in obsessive compulsive disorder –> these thoughts and behaviours are DISTRESSING and associated with significant anxiety
In obsessive compulsive personality disorder –> these activities are PLEASURABLE and DESIRABLE with no associated distress
What is dysthmyia
A persistent low mood that does not quite meet the criteria for major depressive disorder.
Low mood is NOT the primary symptom.
What is schizotypal personality disorder characterised by?
Unusual social behaviour, bizarre or magical thinking and distorted perceptions.
Unlike schizophrenia, patients are able to maintain a grasp on reality.
What beta blocker can be used to treat the somatic symptoms of generalised anxiety disorder?
Why this one?
Propanolol - is non-selective
Why are atenolol and bisoprolol not suitable for GAD?
Is a cardio-selective beta blocker
What ECG change may be seen in refeeding syndrome?
Why?
Prominent U waves - feature of hypokalaemia
What do prominent U waves on an ECG indicate?
Hypokalaemia
What area of the brain is responsible for the activation of the ‘flight or fight’ response?
Amygdala
–> the left amygdala appears to be larger in individuals with anxiety disorderes
On auscultation of the heart in anorexia nervosa, what is a common finding?
Cause?
Pan-systolic murmur and mitral valve prolapse
Caused by loss of cardiac muscle with the mitral valve remaining the same size
Splitting is a phenomenon seen in which personality disorder?
Emotionally unstable personality disorder
What is splitting?
Relationships alternate between idealisation and devaluation
People with ED may intentionally omit their insulin as a way to reduce weight gain.
How may they present?
DKA - confusion, abdo pain, nausea, vomiting, and dehydration
What test is used to assess muscle wasting in patients with anorexia nervosa?
What is a red flag?
Sit up-squat-stand (SUSS)
Sit up test –> patient lies flat on firm surface (e.g. floor) and attempts to sit up without using hands
Squat test –> patient asked to rise from squatting position without using hands
Inability to stand up from chair without using hands is a RED FLAG indicating severe muscle wasting
How long must the symptoms of post-traumatic stress disorder (PTSD) be present for before a diagnosis can be made?
1 month AND interfering with day-day
Low levels of which neurotransmitter are associated with the development of anxiety?
GABA
What medications predispose to lithium toxicity?
- NSAIDs
- Furosemide
- Thiazide diuretics
- ACE inhibitors
- Some antidepressants
Why do diuretics predispose to lithium toxicity?
Cause reabsorption of lithium.
Particularly thiazides due to their main action in the proximal convoluted tubule, where lithium absorption is higher.
Symptoms of mild lithium toxicity?
N&D, blurred vision, polyuria, dizziness, coarse tremor, muscle weakness, drowsiness
Management of SEVERE lithium toxicity?
Haemodialysis
The dialysis machine can filter lithium out of the blood.
How does dehydration impact lithium levels?
Can increase lithium levels and predispose to toxicity.
Kidneys handle lithium similar to sodium. Loss of salt and water in dehydration leads to retention of lithium (and sodium).
Most common side effects of SSRIs?
- GI upset and peptic ulcers
- Increased anxiety and agitation (in first 2 weeks)
- QT prolongation with citalopram
- Sexual dysfunction
Clinical features of opiate intoxication?
- Drowsiness
- Confusion
- Decreased respiratory rate
- Decreased heart rate
- Constricted pupils
If the substance, such as heroin, has been injected, there may be evidence of needle marks (often referred to as ‘track marks’), abscesses or vein collapse at injection sites
Clinical features of cannabis intoxication?
Common symptoms of cannabis intoxication include drowsiness, impaired memory, slowed reflexes and motor skills, bloodshot eyes, increased appetite, dry mouth, increased heart rate and paranoia
Clinical features of LSD?
Labile mood
Hallucinations
Increased blood pressure
Increased heart rate
Increased temperature
Sweating
Insomnia
Dry mouth
What receptor does LSD act on?
LSD primarily acts at dopamine receptors.
Clinical features of stimulant intoxication (e.g. cocaine, methamphetamine)?
Euphoria
Increased blood pressure
Increased heart rate
Increased temperature
Opiate withdrawal symptoms?
Agitation
Anxiety
Muscle aches or cramps
Chills
Runny eyes
Runny nose
Sweating
Yawning
Insomnia
Gastrointestinal disturbance such as abdominal cramps, nausea, diarrhoea and vomiting
Dilated pupils
‘Goose bump’ skin
Increased heart rate and blood pressure
Who are SNRIs contraindicated in?
History of heart disease and high blood pressure
Why are SNRIs contraindicated in heart disease and high blood pressure?
Due to enhancement of noradrenaline activity, they can cause an increase in BP and HR
What is the impact of taking an antidepressant (e.g. sertraline) and amphetamines?
Can predispose to serotonin syndrome
What medication(s) should be prescribed first line to support detoxification from heroin?
Methadone is 1st line
Buprenorphine is equally suitable but methadone is 1st line (patient dependent)
What class of drug is imipramine?
Tricyclic antidepressant
Most common side effects of tricyclic antidepressants?
They are strongly associated with anti-cholinergic activity. Consequently, the common side effects include:
Urinary retention
Drowsiness
Blurred vision
Constipation
Dry mouth
For how long must symptoms be present for a diagnosis of depression to be made?
14 days
Why can lithium toxicity be precipitated by illness or dehydration?
Leads to retention of lithium
Which antidepressant is indicated in patients who have been previously hospitalised for an MI or unstable angina?
SSRIs
Clinical features of TCA overdose?
- Confusion
- Seizure
- Tachycardia
- Hypotension
- Dilated pupils (mydriasis)
- ECG changes (e.g. prolonged QRS and QTc interval)
- Metabolic acidosis
Management of TCA overdose?
Supportive care and sodium bicarb
Effect of lithium on thyroid levels?
Can lead to hypothyroidism (high TSH but low T3/T4).
Symptoms –> constipation, weight gain, heavy periods, bradycardia, fatigue, hyporeflexia
Management of hypothyroidism when taking lithium?
Thyroxine replacement therapy
What is the pharmacological management in acute opioid withdrawal?
- Methadone (can cause prolonged QTc)
- Lofexidine (a2 receptor agonist)
- Loperamine (for diarrhoea)
- Anti-emetics (for nausea)
- Benzos (for agitation)
What class of drug is Mirtazapine?
NaSSA
Why should SSRIs not be prescribed alongside anticoagulants (e.g. warfarin)?
What should be prescribed instead?
Can increase risk of bleeding (especially among elderly)
Prescribe NaSSA (mirtazapine) instead
General indication of mirtazapine?
2nd line treatment of depression whe n a SSRI is inappropriate or ineffective
What is methyphenidate?
Ritalin
Symptoms of illicit use of ritalin?
- Insomnia
- Restlessness
- Increased temp
- Increased BP
- Increased HR
Which antidepressant is most likely to cause anticholinertic syndrome?
TCAs
Which section of the MHA is often used in an emergency by non-psychiatric trained doctors when patient poses a risk to themselves?
4
What social factors can affect clozapine levels?
Smoking & drinking
Can cause increase in clozapine levels:
- Smoking cessation
- Alcohol binges
Can reduce levels:
- Starting smoking
- Stopping drinking
What class of drug is mirtazapine?
Tetracyclic antidepressants
What is the difference between bipolar disorder type I and bipolar disorder type II?
In bipolar I, the person has experienced at least one episode of MANIA
In bipolar II, the person has experienced at least one episode of hypomania, but NEVER an episode of mania. They must have also experienced at least one episode of major DEPRESSION.
What class of drug is zuclopenthixol decanoate?
Typical antipsychotic
What are potential effects of SSRIs when taking during pregnancy?
Use during the first trimester gives a small increased risk of congenital heart defects
Use during the third trimester can result in persistent pulmonary hypertension of the newborn
Which SSRI has an increased risk of congenital malformations, particularly in the first trimester?
Paroxetine
What class of drug is Duloxetine?
SNRI
What is the SSRI of choice in children and adolescents?
Fluoxetine
After initiating lithum, when should serum lithium levles first be monitored?
1 week - 12 hours after last dose
N.B. when checking lithium levels, the sample should be taken 12 hours post-dose
How should sertraline dose be adjusted prior to ECT treatment?
Reduce BUT not stopped
Which atypical antipsychotic has the most tolerable side effect profile?
Aripiprazole
Depression and dementia can present with similiar symptoms, especially in older patients.
What are some similar sympotms?
How can they be differentiated?
Can both present with memory problems.
Factors suggesting diagnosis of depression over dementia:
- short history, rapid onset
- biological symptoms e.g. weight loss, sleep disturbance
- patient WORRIED about poor memory
- reluctant to take tests, disappointed with results
- mini-mental test score: variable
- global memory loss (dementia characteristically causes RECENT memory loss)
What can cause memory loss in depression?
Lack of concentration
What class of drug can induce psychosis?
Steroids
Steroid-induced psychosis is a recognised side effect of corticosteroid use.
In patients taking antidepressants who present with mania/hypomania, whjat is the management?
Stop antidepressant and start atypical antipsychotics
Why should triptans be avoided in patients taking SSRIs?
Both triptans and SSRIs have serotonergic activity –> can lead to serotonin syndrome (autonomic instability, neuromuscular hyperreactivity, mental status changes)
What class of drug is selegiline?
MOAI
What is the first line treatment for children and young people with anorexia nervosa?
Family based therapy
This approach involves the whole family in the treatment process, recognising their role in supporting recovery. It aims to empower parents to help their child regain weight and challenge eating disorder behaviours, while also addressing any underlying issues within the family dynamic.
When should lithium levels be monitored?
After starting treatment/dose change –> one week and then weekly until the levels are stable.
Once levels are stable –> levels are usually measured every 3 months.
Lithium levels should be measured 12 hours post-dose.
How does acute stress reaction differ from PTSD?
Acute stress disorder is defined as an acute stress reaction that occurs in the 4 weeks after a traumatic event, as opposed to PTSD which is diagnosed after 4 weeks.
Circumstantiality vs tangentiality?
Circumstantiality –> The goal of the conversation is reached in the end by a circuitous route i.e. the patient does eventually answer the question but does so after giving unnecessary and excessive detail, which is a feature of circumstantiality.
Tangentiality –> The patient does NOT return to the topic of conversation. Patients wander away from a topic without returning to it.
Schizoid vs schizotypal personality disorder?
Schizoid:
- Displays the negative symptoms of schizophrenia
- Solitary behaviour, indifference or lack of interest towards others and being affectively detached.
Schizotypal:
- Often diagnosed in people with odd beliefs and magical thinking, ideas of reference with retained insight and odd behaviour.
- Similarly to schizoid personality disorder, people with schizotypal personality disorder often do not form close relationships with friends or partners.
In patients 25 and under, when you should review after starting them on an SSRI?
Patients ≤ 25 years who have been started on an SSRI should be reviewed after 1 week
What class of drug is amitriptyline?
Tricyclic antidepressant
Side effects of tricyclic antidepressants?
- Inhibits serotonin (5-HT) reuptake (increasing conc)
- Inhibits NA reuptake (increases conc)
- antagonism of histamine receptors –> drowsiness
- antagonism of muscarinic receptors –> dry mouth, blurred vision, constipation, urinary retention
- antagonism of adrenergic receptors –> postural hypotension
- lengthening of QT interval
Which personality disorder can be rigid with respect to morals, ethics and values and often are reluctant to surrender work to others?
Obsessive compulsive personality
Initial management of OCD?
Exposure and response prevention
First line management of alcohol withdrawal?
Chlordiazepoxide
The introduction of antidepressants can trigger a manic episode. What is the management of mania/hypomania in patients taking antidepressants?
consider stopping the antidepressant and start antipsychotic therapy
What class of drug is duloxetine?
SNRI
In GAD, if a first line SSRI such as sertraline is ineffective or not tolerated, what should be tried next?
Try another SSRI or an SNRI
What is Charles-bonnet syndrome?
Characterised by visual hallucinations associated with eye disease.
Most common visual hallucinations are faces, children and wild animals.
What investigation should be done in patients presenting with new sudden onset psychosis?
Brain imaging to rule out organic causes such as tumour, stroke –> CT head scan, brain MRI
(especially in the elderly)
In which disorder is there the presence of a delusion that a famous is in love with them, with the absence of other psychotic symptoms?
Erotomania (De Clerambault’s syndrome)
When is the peak incidence of seizures following alcohol withdrawal?
36 hours
In what conditions is ECT indicated?
- Treatment-resistant depression
- Catatonic schizophrenia
- Severe mania
- An episode of moderate depression know to respond to ECT in the past
Short term side effects of ECT?
- Headache
- Nausea
- Memory impairment
- Cardiac arrhythmias
Long term, there are very few effects noted, though rarely patients have long term memory issues.
What class of dtug is clomipramine?
Tricyclic antidepressants
What is the mechanism of action of metoclopramide?
Dopamine receptor antagonist
What can metoclopramide induce when taken with antipsychotics?
Acute dystonic reaction
What can be used in the management of an acute dystonic reaction?
Anticholinergics –> these help decrease muscle stiffness, sweating, and the production of saliva, and helps improve walking ability in people with Parkinson’s disease
E.g. procyclidine
How can a somatisation disorder be distinguised from Munchausen’s syndrome?
Somatisation disorder –> recurrent presentation of physical symptoms e.g. nausea, headaches, and palpitations in the absence of a detectable organic cause. These symptoms are NOT intentionally produced or feigned. The patient may have multiple admissions over years due to these unexplained symptoms, which can cause significant distress and impairment in their daily life.
Munchausen’s (factitious disorder) –> involves individuals deliberately producing or feigning physical or psychological symptoms to assume the sick role.
Following the 2011 NICE guidelines on the management of panic disorder, what is the most appropriate first-line drug treatment?
SSRI
Features of PTSD?
- re-experiencing e.g. flashbacks, nightmares
- avoidance e.g. avoiding people or situations
- hyperarousal e.g.hypervigilance, sleep problems
Difference between flight of ideas and Knight’s move?
Knight’s move –> there are illogical leaps from one idea to another
Fligt of ideas –> there are discernible links between ideas
What are clang associations?
Ideas related only by rhyme or being similar sounding
E.g. ‘How do I feel? Like a wheel that’s rolling away, and I stay and I sway with the breeze’
What class of drug is paroxetine?
SSRI
How can bulimia nervosa affect an ECG?
Can casuse hypokalaemia, leading to palpitations, first-degree heart block, tall P-waves and flattened T-waves
Which atypical antipsychotic drug notably reduces the seizure threshold?
Clozapine
What is the first-line pharmacological therapy for generalised anxiety disorder?
SSRIs
If a patient is establised on an NSAID and are then prescribed an SSRI, what else should they be prescribed?
A proton pump inhibitor (PPI)
SSRI + NSAID = GI bleeding risk –> give a PPI
What tool is used by GP’s to characterise a patient’s severity of depression?
Patient health questionnaire-9 (PHQ-9)
Describe the different categories of depression in the PHQ-9
0-4 –> No depression identified
5-9 –> Mild depression
10-14 –> Moderate depression
15-19 –> Moderately severe depression
20-27 –> Severe depression
What are some useful side effects of Mirtazapine?
Sedation
Increased appetite
Improved mood
What are the symptoms of SSRI discontinuation syndrome?
- increased mood change (e.g. anxiety)
- restlessness
- difficulty sleeping
- unsteadiness/dizziness
- sweating
- gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
- paraesthesia (electric shock sensations)
What is SSRI discontinuation syndrome?
Can occur when suddenly stopping or reducing SSRIs
What are the 5 stages of grief?
- Denial - this may include a feeling of numbness and also pseudohallucinations of the deceased, both auditory and visual (people may focus on physical objects that remind them of their loved one or even prepare meals for them)
- Anger - this is commonly directed against other family members and medical professionals
- Bargaining
- Depression
- Acceptance
It should be noted that many patients will NOT go through all 5 stages.
What are some features of an atypical grief reaction?
Delayed grief: sometimes said to occur when more than 2 weeks passes before grieving begins.
Prolonged grief: difficult to define. Normal grief reactions may take up to and beyond 12 months.
When are abnormal, or atypical, grief reactions more likely to occur?
More likely to occur in women and if the death is sudden and unexpected.
Other risk factors include a problematic relationship before death or if the patient has not much social support.
Hypochondriasis vs somatisation disorder?
Hypochondriasis (or illness anxiety disorder):
- Describes a persistent belief in the presence of an underlying serious disease.
- A helpful way of remembering this is hypochondriasis is worrying about cancer (as they both contain the letter C and it is an example of a serious underlying disease).
Somatisation disorder:
- This is characterised by the persistent belief of multiple physical symptoms lasting for at least 2 years despite being given reassurance and negative test results.
- SomatiSation disorder is worrying about multiple physical Symptoms (as they both contain the letter S).
What is the form of thought disorder where the patient repeats someone else’s speech including the questions being asked?
Echolalia
How can tardive dyskinesia present?
Tardive kinesia can present as chewing, jaw pouting or excessive blinking due to late onset abnormal involuntary choreoathetoid movements in patients on conventional antipsychotics
What is an appropriate non-pharmalogical treatment for borderline personality disorder/EUPD?
Dialectical behaviour therapy (DBT)
This is a targeted therapy that is based CBT, but has been adapted to help people who experience emotions very intensely.
How can atypical antipsychotics affect blood glucose levels?
Can cause dysglycaemia (e.g. raised gasting blood glucose)
As well as other metabolic side effects e.g. dyslipidaemia, diabetes mellitus
What is catatonia?
Stopping of voluntary movement or staying still in an unusual position
Pharmacological management of acute dystonia secondary to antipsychotics?
Procyclidine
For insomnia to be classed as ‘chronic’, how long must it be present for?
At least 3 months
BUT it only needs to be present for 3 out of 7 nights in the week.
At what age can a diagnosis of a personality disorder be made?
18 and over
Mechanism of mertazapine?
Mirtazapine is an atypical antidepressant and is used primarily for the treatment of a major depressive disorder.
Mirtazapine is in a group of tetracyclic antidepressants (TeCA).
Mirtazapine inhibits the central presynaptic alpha-2-adrenergic receptors, which causes an increased release of serotonin and norepinephrine.
What age group is a risk factor for the development of GAD?
35-54
Give some risk factors for the development of GAD
Aged 35- 54
Being divorced or separated
Living alone
Being a lone parent
What type of urinary incontinence is the most associated with amitriptyline?
Overflow incontinence
TCAs have anticholinergic effects which may lead to urinary retention, leading to frequent leaking.
What is a brief psychotic disorder?
This describes an episode of psychosis lasting less than a month with a subsequent return to baseline functioning.
What conditions is dialectical behaviour therapy indicated in?
generally used in the management of personality disorders
What is the 1st line management in OCD with MILD impairment?
CBT including exposure and response prevention (ERP)
Is CBT indicated in schizophrenia?
Yes - CBT is recommended for all people with schizophrenia.
This form of therapy helps patients deal with their symptoms by changing the way they think and behave. It can reduce the severity of symptoms and improve quality of life.
What is a potential risk of fluoxetine when used in the third trimester of pregnancy?
Persistent pulmonary hypertension
What is the most appropriate first-line treatment in PTSD?
Trauma-focused CBT or eye movement desensitisation and reprocessing therapy (EMDR)
How can concordance with antipsychotics be improved?
With depot medication
What is sleep paralysis?
Sleep paralysis is a condition characterized by the inability to move or speak when transitioning between sleep and wakefulness, either when falling asleep or upon awakening.
It can be accompanied by vivid hallucinations, which may explain the patient’s description of seeing another person in the room.
Sleep paralysis is generally harmless but can cause significant anxiety for those who experience it.
What is Hoover’s sign?
Hoover’s sign is a quick and useful clinical tool to differentiate organic from non-organic leg paresis.
With the patient in the supine position, ask them to raise their right leg against resistance whilst keeping it straight. Places your hand under the left heel as they do this.
Positive test –> pressure felt under the paretic leg when lifting the non-paretic leg against pressure due to involuntary contralateral hip extension.
If this test is positive, could indicate a conversion disorder (i.e. no organic cause).
Mania vs hypomania?
Hypomania is characterised by elevated mood, pressured speech and flight of ideas but without psychotic symptoms
Patients with hypomania can experience disinhibition such as increased sexuality, increased spending or taking risks that they wouldn’t normally.
Features that differentiate this presentation from that of mania include the time frame (less than 7 days) and the lack of psychotic symptoms (hallucinations).
What medication is most suitable for treating tardive dyskinesia (as a result of long-term antipsychotics)?
Tetrabenazine
What electrolyte abnormality can SSRIs cause?
Hyponatraemia
If an SSRI and NSAID are prescribed together, what else should be prescribed?
PPI e.g. omeprazole
What class of drug is mefenamic acid?
NSAID
Which NSAID can be taken to help alleviate heavy bleeding in periods?
Mefenamic acid
Side effects of zopiclone?
- Agitation
- Bitter taste in mouth
- Constipation
- Decreased muscle tone
- Dizziness
- Dry mouth
- Increased risk of falls (especially in the elderly)
Tangentiality vs flight of ideas?
Flight of ideas –> where patients jump from one topic to the next with discernible links between them. Speech at fast rate.
Although tangentiality also has this feature, in flight of ideas the question would’ve first been answered, then the patient would have jumped to the next topic. In flight of ideas the speech would also be at a faster rate.
Tangentiality –> where patients wander away from a topic without returning to it, usually with loosely discernible links.
Memory loss in severe depression vs demenita?
Dementia –> memory loss of recent events
Depression –> global memory loss (pseudodementia)
Before starting venlafaxine, what should be monitored at initiation and dose titration of this medication?
Blood pressure –> SNRIs are associated with the development of hypertension
What investigation is needed prior to starting citalopram or escitalopram?
ECG –> QT prolongation, and/or ventricular arrhythmias including torsade de pointes have been reported in people taking citalopram or escitalopram
A 75-year-old woman presents to the emergency department with new onset confusion.
She is taking sertraline.
What blood test would you want?
U&Es –> risk of hyponatraemia
Knights move vs flight of ideas?
Knight’s move thinking there are illogical leaps from one idea to another, flight of ideas there are discernible links between ideas
What are the features of post-concussion syndrome?
headache
fatigue
anxiety/depression
dizziness
Who do patients with schizotypal personality disorder often maintain close relationships with?
Family members
A 45-year-old man describes successful abstinence from alcohol for the past six months following inpatient detoxification. During his admission, he was started on a ‘deterrent’ medication. He takes this medication daily and reports that if he consumes alcohol he will ‘violently vomit’.
Which medication is the patient describing?
Disulfiram
What is an ‘anti-craving medication’ in alcohol detoxification?
Acamprosate
In GAD, if a first line SSRI such as sertraline is ineffective or not tolerated, what should be tried next?
SNRI e.g. duloxetine
If clozapine doses are missed for more than 48 hours, what should be done?
The dose will need to be restarted again slowly (i.e. retitrated)
For moderate/severe OCD, what drug may be used as an alternative first-line drug treatment to an SSRI?
Clomipramine (tricyclic antidepressant)
Which antipsychotic is the most effective for dealing with negative symptoms?
Clozapine
Suicide risk factors?
- male sex (hazard ratio (HR) approximately 2.0)
- history of deliberate self-harm (HR 1.7)
- alcohol or drug misuse (HR 1.6)
- history of mental illness
- depression
- schizophrenia: NICE estimates that 10% of people with schizophrenia will complete suicide
history of chronic disease - advancing age
- unemployment or social isolation/living alone
being unmarried, divorced or widowed
What class of drug is selegiline?
MAOI
After a change in dose, how often should lithium levels be monitored?
One week after dose change and then weekly until levels are stable
What class of drug is rasagiline?
MAOI
What scoring system can be used to assess alcohol withdrawal severity?
Clinical Institute Withdrawal Assessment (CIWA-Ar)
Which SSRI is the most likely to lead to QT prolongation and Torsades de pointes?
Citalopram
What is the Alcohol Use Disorders Identification Test (AUDIT)?
A test to assess whether there is a need for a specialist evaluation concerning alcohol consumption.
What is logoclonia?
A phenomenon in Parkinson’s disease where the patient gets ‘stuck’ on a particular word of a sentence and repeats it.
What is a bizarre delusion?
Where a person is adament about a belief that is impossible, not understandable, and unrelated to normal life.
Where is the majority of alcohol absorbed?
Up to 80% is absorbed through the proximal intestine
What is transient global amnesia?
Transient global amnesia (TGA) is a temporary, abrupt neurological condition characterized by sudden memory loss, affecting both short and long term memory while leaving other cognitive functions intact.
What are the key features of TGA?
Disorientation, inability to form new memories, and an unaffected sense of self-identity
- Sudden onset of memory loss, affecting both the ability to recall past events (retrograde amnesia) and form new memories (anterograde amnesia)
- Repetitive questioning due to memory loss
- Confusion or feeling lost, even in familiar surroundings
- Clear consciousness and preserved personal identity
- Unaffected motor skills, allowing individuals to maintain their regular physical activities
- Spontaneous resolution of symptoms, typically within 24 hours
When should lithium be stopped in pregnancy? Why?
In the first trimester
Lithium is known for increasing the risk of developing Epstein’s abnormality
What is Epstein’s abnormality?
The leaflets of the tricuspid valve are displaced, resulting in a large right atrium and a small right ventricle
What is the 1st line non-pharmacological management for agitated patients?
Assign a 1-1 nurse and re-orientation
