Day 3 PSYCH Flashcards
While working in psychiatry you are taking a history from a patient with a new diagnosis of generalised anxiety disorder (GAD). You take a thorough past medical history.
Which of the risk factors for developing GAD? (4)
Aged 35- 54
Being divorced or separated
Living alone
Being a lone parent
A 35-year-old female presents to the Emergency Department following a deliberate paracetamol overdose.
Which one of the features are most indicative of a continuing high risk of suicide?
If a patient has actually attempted suicide, there are a number of factors associated with an increased risk of completed suicide at a future date:
- efforts to avoid discovery
- planning
- leaving a written note
- final acts such as sorting out finances
- violent method
A 25-year-old man presents to his GP for a review of his current medication.
He was started on citalopram for the treatment of depressive symptoms four months ago. Today he feels that his symptoms have much improved, and he feels back to his normal self. The patient states that he feels he no longer needs to be on this antidepressant medication.
In order to reduce the chances of relapse, what should the GP advise?
Antidepressants should be continued for at least 6 months after remission of symptoms to decrease risk of relapse
A 22-year-old man has been admitted to the psychiatric ward following concerns from his GP that he was experiencing symptoms of psychosis. The psychiatric team is considering a diagnosis of schizophrenia.
Which features in the history would be most consistent with this diagnosis?
Sleep disturbances, most commonly insomnia, are often reported by patients as their symptoms of schizophrenia develop.
A 68-year-old Asian lady presenting with a sudden onset of paranoid thoughts and suicidal ideation was admitted under section 2 of the Mental Health Act for a period of assessment.
Her past medical history consisted of hypertension, type 2 diabetes mellitus and hypercholesterolaemia.
Considering this first episode of sudden onset psychosis in an elderly lady, what important investigation is required to rule out other secondary causes?
A CT head scan should be considered in elderly patients with new sudden onset psychosis to rule out an organic cause for their presentation
A 37-year-old male presents to the emergency department with new-onset symptoms.
He has a complex past medical history, comprising of depression, schizophrenia, asthma, and rheumatoid arthritis.
One hour ago, his left eye deviated upwards and inward and he started blinking repeatedly.
The episode lasted three minutes and there was no loss of consciousness.
Additionally, he experienced severe neck pain following the episode. Now, he is feeling well in himself.
Which psychiatric medication is the most likely to have caused the symptoms?
Acute dystonic reactions are an adverse effect of antipsychotic medications
The correct answer is chlorpromazine. This patient is describing an oculogyric crisis, a type of acute dystonic reaction.
These reactions are associated with first-generation antipsychotics, as they most commonly cause extrapyramidal side effects.
The aetiology of the reaction is not fully understood. The crisis can be managed using procyclidine, an anticholinergic.
A 25-year-old man presents with depressed mood for 6 months. He reports feeling fatigued and suicidal on a daily basis. His clothes are dirty and he looks unkempt. He has made five suicide attempts in the last three months.
The patient’s psychiatrist decides to manage this patient’s depression with electroconvulsive therapy (ECT), which is to begin in a week. The patient is currently on sertraline medication of 100mg per day.
What is the most appropriate action to take with regards to this medication prior to ECT treatment for this patient?
Antidepressant medication should be reduced but not stopped when a patient is about to commence ECT treatment
A 23-year-old man undergoes electroconvulsive therapy (ECT) for treatment-resistant depression.
Which of the side effects is he most likely to experience?
Immediate side effects
Drowsiness
Confusion
Headache
Nausea
Aching muscles
Loss of appetite
Long term side effects
Apathy
Anhedonia
Difficulty concentrating
Loss of emotional responses
Difficulty learning new information
A 45-year-old man who takes chlorpromazine for schizophrenia presents with severe restlessness.
What side-effect of antipsychotic medication is this an example of?
Extrapyramidal side-effects (EPSEs)
- Parkinsonism
- acute dystonia - sustained muscle contraction (e.g. torticollis, oculogyric crisis), may be managed with procyclidine
- akathisia (severe restlessness)
- tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)
A 33-year-old male presents after his partner encouraged him to see the GP. He has had hyperarousal to loud noises and difficulty concentrating at work following a stay in the Intensive Care Unit 6 weeks ago. His partner did some reading online and feels he is suffering from an acute stress disorder.
You advise him that he has post-traumatic stress disorder (PTSD) and discuss treatment options. He asks what the difference is, so that he can explain it to his partner. You advise there are similarities in the presentation and the main difference is temporal.
What is the earliest stage after the event that you could confirm this diagnosis?
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
A presentation of these symptoms at 2 weeks would suggest acute stress disorder.
Acute stress disorder and PTSD have similar features. In PTSD this includes:
Re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
Avoidance: avoiding people, situations or circumstances resembling or associated with the event
Hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
Emotional numbing - lack of ability to experience feelings, feeling detached
Following the 2011 NICE guidelines on the management of panic disorder, what is the most appropriate first-line drug treatment?
Drug treatment
NICE suggest sertraline should be considered the first-line SSRI
if sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI) - examples of SNRIs include duloxetine and venlafaxine
If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm.
Weekly follow-up is recommended for the first month
Which are the first-rank symptoms of schizophrenia?
(4)
Delusional perceptions
Passivity phenomena
Thought disorder
Auditory hallucinations
A 48-year-old woman is reviewed in the clinic.
She was recently seen by the psychiatrist and it was recommended that her lithium dose was increased for better symptom control.
Her renal function is stable and so you prescribe the increased dose of lithium that is recommended.
When would it be most appropriate to re-check her levels?
After a change in dose, lithium levels should be taken a week later and weekly until the levels are stable
A 25-year-old male presents to his GP after being asked by his friends to come.
During the appointment, he reveals that that he believes that everyone is able to hear his thoughts, like he is a radio station and that he can hear voices commenting on his behaviour.
On observation, he has a blunted affect, alogia and avolition.
The GP also notices that the patient repeats the last word of any question that he is asked.
What is this phenomena called?
Echolalia is the repetition of someone else’s speech including the questions being asked
A 46-year-old man with schizophrenia is brought to the surgery by one of his carers.
His current medication includes clozapine and procyclidine.
His carer reports that he is more tired than usual and generally unwell.
She also thinks he may have put on weight.
What is the most important test to perform?
Agranulocytosis/neutropenia is a life-threatening side effect of clozapine - monitor FBC
Apart from the unshakeable belief that the famous actor is in love with her, the mental status examination is normal.
What is the correct description of this disorder?
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
Which condition describes delusional parasitosis and describes the delusion of infestation.
Ekbom syndrome
Which condition describes a delusion of sexual infidelity on the part of a sexual partner?
Othello syndrome
Which condition describes a delusion of identifying a familiar person in various people they encounter.
De Frégoli syndrome
Which syndrome describes a delusion that a person closely related to the patient has been replaced by an impostor?
Capgras syndrome
A 44-year-old man attends his GP surgery. He explains that his long term partner died last month. When he woke up this morning he thought he was lying next to her. He claims he heard her voice saying his name. Although he realizes this is not possible it has caused him significant distress. He is worried that he may be ‘going mad.’ He has no other psychiatric history of note.
What is the most likely diagnosis?
Pseudohallucinations are more common after bereavement and do not imply psychosis
There is no mention of pseudohallucinations in either the ICD10 nor the DSM-5. However, there is a generally accepted definition that a pseudohallucination is a false sensory perception in the absence of external stimuli when the affected is aware that they are hallucinating.
A 49-year-old male presents to your surgery complaining of feeling depressed because he is convinced that his wife is being unfaithful. They have just celebrated their 25th wedding anniversary and throughout the marriage they have always been dedicated to one another and he is his wife’s sole carer, as she is bedbound.
Considering the history, you wonder how likely it is that his claims are true.
What is the medical name for delusional jealousy?
Othello syndrome - delusional jealously, usually believing their partner is unfaithful
A 53-year-old gentleman with a long-term diagnosis of paranoid schizophrenia has a relapse in symptoms after not taking his medications regularly, resulting in an admission under section 2 of the Mental Health Act following a formal assessment of his mental state.
His long-term medication was Risperidone orally once daily which had stabilised his mental state for numerous years in the community.
Given his non-compliance, what would be the best suitable treatment option for this patient?
once a month IM depot anti-psychotic injection
A 62-year-old man is admitted to the psychiatric ward after his wife raised concerns about his behaviour.
When you speak to the patient you note that his speech is rapid and you are unable to interrupt him to ask questions.
He frequently changes the topic of conversation, but you can identify links between the different topics.
What psychiatric condition is this symptom most commonly associated with?
Flight of ideas is a feature of mania - bipolar
A 14-year-old girl with Tourette’s syndrome is brought to the GP by her mother as she is worried about some odd behaviours she has noticed.
During the consultation, you find that she has been very worried about her exam results.
She has felt the urge to clean all the door handles in the house 3 times each morning as otherwise, she finds herself worrying more about these exams.
Which of the following features would point towards a diagnosis of psychosis over obsessive-compulsive disorder?
Obsessive-compulsive disorder can be differentiated from psychosis by the level of insight into their actions
She truly believes that if she does not perform these acts that she will definitely fail her exams
A 23-year-old man has a known psychiatric disorder. His condition causes him to have persecutory delusions and poor organisation of thoughts. He is easily distracted and struggles to maintain good eye contact during conversations.
What factor is associated with poor prognosis in this condition?
low iq
A 23-year-old male has been on antipsychotics for the past few months. He has been suffering from a side-effect of this drug, that you grade as severe, which causes repetitive involuntary movements including grimacing and sticking out the tongue. This side-effect is known to arise only in individuals who have been on antipsychotic for a while.
Which medication is therefore most suitable to treat this side-effect?
This patient is suffering from tardive dyskinesia. The episode has been described as severe and so the most appropriate treatment is tetrabenazine.
