Day 2 PSYCH

Question 1

A 14-year-old girl is diagnosed with anorexia nervosa.

Her parents initially presented as they had noticed she was severely limiting her dietary intake and losing weight.

What treatment is she most likely to be offered?

Answer 1

focused family therapy is the first-line treatment for children and young people with anorexia nervosa

For adults with anorexia nervosa, NICE recommend we consider one of:

• individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
• Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
• specialist supportive clinical management (SSCM).

Question 2

What is the definition of mania?

Answer 2

Mania is a persistently elevated mood state with psychotic symptoms

Question 3

What is the difference between mania and hypomania?

Answer 3

Hypomania is a milder version of mania that lasts for a short period (usually a few days) Mania is a more severe form that lasts for a longer period (a week or more)

Question 4

A 45-year-old man with schizophrenia taking chlorpromazine develops a bilateral resting tremor. What side-effect of antipsychotic medication is this an example of?

Answer 4

Parkinsonism

Question 5

A 34-year-old man originally from West Africa is seen by his GP in January with depression.

There is no past medical history of note but he is known to smoke cannabis.

He has had similar episodes for the past two winters. What is the most likely diagnosis?

Answer 5

Seasonal affective disorder

Question 6

The patient’s mother states that for the past 6 days, he has been exhibiting odd behaviour - claiming he has been sent by God to save his people. He was returned to his home by a neighbour after being found stopping traffic on a busy road to ‘warn them about the impending apocalypse’. The patient reports he ‘does not have time to sleep’ as he must spread the news.

What is the most appropriate next step?

Answer 6

Symptoms of mania in primary care: Urgent referral to CMHT

Question 7

A patient you are looking after is started on imipramine for depression.

Which combination of side-effects is most likely to be seen in a patient taking this class of antidepressants?

Answer 7

Tricyclic antidepressants (TCAs) are used less commonly now for depression due to their side-effects and toxicity in overdose. They are however used widely in the treatment of neuropathic pain, where smaller doses are typically required.

Common side-effects

drowsiness

dry mouth

blurred vision

constipation

urinary retention

lengthening of QT interval

Question 8

TCA sides effects

Answer 8

drowsiness

dry mouth

blurred vision

constipation

urinary retention

lengthening of QT interval

Question 9

A 21-year-old woman presents to her GP, seeking help for anxiety. She finds her office-based job stressful, especially the aspects involving discussions with colleagues and bosses, fearing criticism. Outside of work, she often finds herself worrying about what her friends think of her, and increasingly forgoes social interaction with them as a result. She mentions that she thinks quite lowly of herself and does not have much self-esteem.

What best fits her diagnosis?

Answer 9

Patients with avoidant personality disorder are fearful of criticism, being unliked, rejection and ridicule

Question 10

John is a 19-year-old man who has just started his first year at university. He is described by others as quite a cold character. He has one friend but prefers solitary activities and has few interests. John has never had a girlfriend and does not seem to be interested in companionship. When he is praised or criticised by others, he remains indifferent to their comments. There is no history of low mood or hallucinations.

Which of the following is the most likely diagnosis?

Answer 10

Schizoid personality disorder displays the negative symptoms of schizophrenia

Question 11

A 33-year-old woman presents to her GP with a several-month history of anxiety with no clear trigger which is affecting her sleep and desire to interact with others. She feels restless and agitated. She denies any episodes of panic attacks. Her medical history is otherwise unremarkable.

Which of the following would be the most appropriate option to try first?

Answer 11

SSRIs are the first-line pharmacological therapy for generalised anxiety disorder

Question 12

A 60-year-old-male goes to his GP complaining of forgetfulness for the past 2 months. He has difficulty remembering details such as leaving the kettle on and where he left his keys. He works as the director of a pharmaceutical company and describes stress at work. He also has difficulty sleeping at night. His mini mental state examination (MMSE) score is 26 out of 30. Patient answered ‘I don’t know’ to the last two letters when asked to spell WORLD backwards. His medical history includes hypertension and gout.

What is the most likely diagnosis?

Answer 12

depression

Question 13

A 23-year-old woman has a diagnosis of obsessive-compulsive disorder but, despite cognitive behavioural therapy and fluoxetine treatment, she is still experiencing severe symptoms. She is started on clomipramine and the doctor warns her of some possible side effects. Which of the following side effects is she most likely to be affected by due to the clomipramine?

Answer 13

Dry mouth (anticholinergic) and weight gain (antihistaminic) are side effects of clomipramine (TCAs)

Question 14

A 32-year-old man with a longstanding moderate depression comes to see his GP after recently being started on a new medication by his psychiatrist. He complains that his appetite has increased hugely and as a result, he has put on a significant amount of weight. He is also constantly tired and is struggling to concentrate at work.

Which of the medication has most likely been started?

Answer 14

mirtazapine

Question 15

Which therapy is targeted towards personality disorder patients?

Answer 15

DBT

Question 16

A 31-year-old nulliparous woman presents for the first time in her pregnancy at 29 weeks. Her current medications include: fluoxetine and lactulose. She wants to know what risk her medications might have to her baby.

What is a potential risk of fluoxetine when used in the third trimester of pregnancy?

Answer 16

SSRI use during third trimester - risk of persistent pulmonary hypertension of the newborn

Question 17

What is the difference between acute stress disorder and post-traumatic stress disorder?

Answer 17

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

Question 18

A 23-year-old male presents to his GP two weeks after a road traffic accident concerned about increased anxiety levels, lethargy and headache. At the time he had a CT brain after banging his head on the steering wheel, which revealed no abnormality. Six months following this episode his symptoms have resolved. What did his original symptoms likely represent?

Answer 18

Post-concussion syndrome is seen after even minor head trauma

Typical features include

• headache
• fatigue
• anxiety/depression
• dizziness

Question 19

Whenever you ask question, you notice that a patient repeats the question back to you. You notice that he is also repeating some of the phrases you use.

What form of thought disorder is this an example of?

Answer 19

Echolalia is the repetition of someone else’s speech including the questions being asked

Question 20

You review a patient who has been taking citalopram for the past two years to treat depression. He has felt well now for the past year and you agree a plan to stop the antidepressant. How should the citalopram be stopped?

Answer 20

When stopping a SSRI the dose should be gradually reduced over a 4 week period

This not necessary with fluoxetine due to its longer half-life.

Question 21

A 41-year-old male has been on olanzapine for the past 2 years. He has recently looked up the side-effects of the drugs after suffering from an episode of tardive dyskinesia.

Which biochemical side-effect would this patient most likely suffer from?

Answer 21

Metabolic side effects of antipsychotics include dysglycaemia, dyslipidaemia, and diabetes mellitus

Question 22

A 36-year-old male presents to his general practitioner with some troublesome symptoms that have started recently. He has a past medical history of schizophrenia, diagnosed when he was twenty, which is currently treated with olanzapine. He has had no surgeries and is otherwise fit and well.

Which symptoms is he most likely to experience?

Answer 22

Long-term atypical antipsychotics can lead to the development of glucose dysregulation and diabetes

Question 23

During a ward round consultation, the Psychiatrist was assessing a patient’s current mental state. The patient’s reply to most of the questions consisted of sentences which did not make any sense such as - ‘painting pizza prince bus brush’. This is a good example of which of the following thought disorder?

Answer 23

Disorganised speech in the form of ‘word salad’ is associated with psychosis and mania

Question 24

Steven is a 40-year-old male that was diagnosed with post-traumatic stress disorder (PTSD) following a motorcycle accident two years ago. Since the accident, Steven has had a lot of trouble with sleep. He finds that he often wakes up in the night due to nightmares and struggles to get back to sleep. He finds this is having a big impact on his day to day life as he no longer has the energy to play with his young children.

Steven has undertaken several sessions of cognitive behavioural therapy (CBT), but he has found this has had little effect on his symptoms.

What would be the appropriate drug treatment in the management of Steven’s condition?

Answer 24

Venlafaxine is the correct answer. The first-line drug treatment for PTSD is venlafaxine or a selective serotonin reuptake inhibitor (SSRI) such as sertraline.

Question 25

You suspect a patient to have obsessive-compulsive disorder and agree to refer him to the community mental health team. What treatment is he most likely going to be offered?

Answer 25

OCD with mild impairment: low-intensity psychological treatments: cognitive behavioural therapy (CBT) including exposure and response prevention (ERP) is first-line

Question 26

A 29-year-old woman is brought to the emergency department by the police after trying to break into a movie set. She stated that she was ‘only there to see the actor’ which whom she claimed she has a romantic relationship. She has never met the actor before though has repeatedly sent him letters over the years. She describes her mood as ‘excellent.’ She denies any auditory or visual hallucinations. Her appearance is normal and her speech is clear and unremarkable.

Given her behaviour, what is the most likely diagnosis?

Answer 26

Erotomania (De Clerambault’s syndrome) is the presence of a delusion that a famous is in love with them, with the absence of other psychotic symptoms

Question 27

What are Gitelman and Bartter’s syndrome?

Answer 27

Gitelman and Bartter’s syndromes are rare genetic kidney disorders that result in a metabolic alkalosis but these would present in a different manner.

Question 29

see the team doctor due to an unusual sensation in his legs. He describes a numb sensation below his knee. On examination the patient there is apparent sensory loss below the right knee in a non-dermatomal distribution. The team doctor suspects a non-organic cause of his symptoms. This is an example of a:

Answer 29

Conversion disorder - typically involves loss of motor or sensory function. May be caused by stress

Question 30

What is a conversion disorder

Answer 30

Conversion disorder - typically involves loss of motor or sensory function. May be caused by stress

Question 31

A 25-year-old woman sees her psychiatrist for review following management and treatment for an episode of moderate depression disorder. From the patient’s history, her psychiatrist believes that the patient’s early morning waking is the symptom most troubling her at the moment.

What is the best description for this type of symptom?

Answer 31

Early morning waking is the best example here of a somatic symptom.

Other examples of somatic symptoms (sometimes referred to as biological/melancholic symptoms (DSM-V) or vital symptoms) include:

• Loss of emotional reactivity
• Diurnal mood variation
• Anhedonia
• Early morning waking
• Psychomotor agitation or retardation
• Loss of appetite and weight
• Loss of libido

Question 32

An 82-year-old man presents with low mood, lack of energy and a loss of interest in activities. His sleep has been poor for 3 weeks and he has not been interested in food. His doctor starts him on mirtazapine. What class of drugs does mirtazapine belong to?

Answer 32

Mirtazapine is a noradrenergic and specific serotonergic antidepressant which increases release of neurotramsitters by blocking alpha2 adrenoreceptors

Question 33

What is circumstantiality?

Answer 33

This is demonstrated by the long-winded nature of an answer.

Question 34

A 72-year-old man who is having trouble sleeping is prescribed temazepam. What is the mechanism of action of temazepam?

Answer 34

Benzodiazepines enhance the effect of GABA, the main inhibitory neurotransmitter

Question 35

Tony is a 40-year-old male who has recently presented to the crisis team with suicidal ideation. Upon further questioning Tony also reports having low mood, lack of energy, waking up early in the morning, and a lack of concentration. Tony says that these symptoms are there most of the time, however he does have good days and bad days. There is no previous psychiatric history. What is the most appropriate drug to start Tony on?

Answer 35

If this is the first episode of depression, consider:

• Prescribing a generic selective serotonin reuptake inhibitor (SSRI), such as citalopram, fluoxetine, paroxetine, or sertraline.

If the person has a chronic physical health problem:

• Sertraline may be preferred, because it has a lower risk of drug interactions.

Question 36

You are working in a GP surgery and your next patient is Susan, a 30-year-old woman with a diagnosis of generalised anxiety disorder (GAD). She is currently prescribed sertraline 200mg daily.

On review of her symptoms today, she states that she does not feel like the sertraline is helping, and she remains anxious almost all of the time. She experiences frequent episodes where she feels her heart pounding in her chest and her head is spinning. Furthermore, she notes that she often struggles to get to sleep and can lie awake for hours at night.

As you observe Susan, she appears obviously distressed. She seems unable to sit still in her chair and is trembling slightly.

What would be the next step in Susan’s management?

Answer 36

The correct answer is to change the prescription to duloxetine. This is because in the management of generalised anxiety disorder (GAD), if first-line management with a selective serotonin reuptake inhibitor (in this case sertraline) is ineffective, an alternative selective serotonin reuptake inhibitor (SSRI) or a serotonin-norepinephrine reuptake inhibitor (SNRI) should be offered. Duloxetine is an SNRI.

Question 37

What class of drug is mirtazapine?

How does it work?

Answer 37

Mirtazapine is a noradrenaline and serotonin selective antidepressant (NaSSA). It is sometimes used in the treatment of depression as an alternative for a poorly tolerated/ineffective antidepressant or as an augment to ongoing treatment. It has been shown to have an effect on controlling the symptoms of anxiety, but at present, it is not part of the NICE guidance for drug treatment of GAD.

Question 38

A 32-year-old man visits his GP, troubled by some thoughts he is having. For several weeks now, he has been having thoughts of needing to repeatedly check that his front door is locked when leaving the house, despite knowing he locked it. He occasionally feels a need to physically check the front door, but more often than not, it is just thoughts.

He denies low mood or any delusions/hallucinations. He is otherwise physically well and has no past medical history, nor family history. He does not take any regular medication.

Given the likely diagnosis, which of the following is recommended first-line?

Answer 38

Exposure and response prevention involves exposing a patient with OCD to an anxiety provoking situation (e.g. having dirty hands)