Day 4 PSYCH Flashcards
A 32-year-old male with a diagnosis of schizophrenia presents to his GP to discuss a pain in his knee. He begins to describe his problem with the following sentence:
‘I’m here today to talk about a pain in my knee, the problem is that I lost my wallet this morning and I suppose I’ve been wondering whether purple is my favourite colour because yesterday the weather was terrible!’
Which of the following signs of thought disorder is this patient demonstrating in his speech?
Differentiating between Knight’s move and 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
A 54-year-old man attends his GP. He was started on fluoxetine eight weeks ago for depression and is now requesting to stop his medication as he feels so well. What should be recommended regarding his treatment?
it should be continued for at least 6 more months
What are the main side effects of SSRIs?
Sertraline
Citalopram
Fluoxetine
there is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID
patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI
fluoxetine and paroxetine have a higher propensity for drug interactions
citalopram (although see below re: QT interval) and fluoxetine are currently the preferred SSRIs
What type of counselling should be given to patients before they start taking an SSRI?
patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI
What is the major contra-indication to citalopram?
(2)
it advised that citalopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in those with: congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval
the maximum daily dose is now 40 mg for adults; 20 mg for patients older than 65 years; and 20 mg for those with hepatic impairment
What are the most important drug interactions with SSRIs?
(5)
- NSAIDs: NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
- warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
- aspirin: see above
- triptans - increased risk of serotonin syndrome
- monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome
A 90-year-old woman with no past medical history presents with increasing forgetfulness. Her daughter is worried that over the last four weeks her mother has been forgetting her grandchildren’s names and stories from her upbringing. The patient states that she has had a loss of appetite, sometimes forgetting if she has eaten, is not getting good quality sleep and is angry with her daughter for taking her to the doctors. She sometimes sees and hears her recently deceased husband.
The mini-mental test score is 17/30 and the patient is not happy with this result.
What is the most likely diagnosis in this case?
Depression is the correct answer.
This is a classical presentation of pseudodementia - the most common mimic for dementia amongst elderly patients.
Although there is evidence of some cognitive impairment, the key feature present is a global memory loss affecting both short and longer-term memory, over a short history of four weeks with reluctance to engage with clinical assessment.
These symptoms, coupled with the recent loss of her husband, indicate a severe reactive depressive episode.
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
Disulfiram (also known as Antabuse) is an irreversible inhibitor of acetaldehyde dehydrogenase. This inhibition causes the buildup of acetaldehyde. The build-up of acetaldehyde within twenty to thirty minutes of alcohol consumption results in unpleasant symptoms, including facial flushing and nausea and vomiting.
The reaction can be life-threatening, so disulfiram is not recommended for patients with underlying frailty, neurological, cardiac or hepatic conditions. Disulfiram is taken once daily and its effects last seven days, working as a deterrent to prevent alcohol relapse. This description is most consistent with the details provided in the vignette.
A 45-year-old man describes successful abstinence from alcohol for the past six months following inpatient detoxification. During his admission, he was prescribed an ‘anti-craving medication’.
He takes this medication three times a day and would like you to continue the prescription as he finds it very helpful. It is safe in combination with alcohol and he has experienced no side effects.
Acamprosate (or Campral) is taken three times a day and has shown to be effective in preventing alcohol relapse in combination with psychological support following detoxification in alcohol dependence syndrome.
It is typically described as an ‘anti-craving’ medication and the underlying mechanism of action remains unclear.
Acamprosate has a minimal side-effect and risk profile and is safe in combination with alcohol.
A 38-year-old man presents with opioid dependence syndrome presents to clinic. He currently takes 30 mL of methadone daily.
He wishes to come off of his methadone as he finds it too sedating and is finding the stigma of being on methadone challenging.
He reports friends have successfully come off methadone after stitching to a ‘tablet that goes under your tongue’ and wishes to try this.
Buprenorphine is a mixed opioid agonist/antagonist. It is typically given as a sublingual tablet and provides an alternative opiate replacement therapy to methadone.
Patient’s often describe buprenorphine as less sedating, which can be a benefit or drawback depending on the context and patient.
Prescribers must also be aware that because of the opioid antagonist properties of methadone it can render regularly prescribed analgesia, such as co-codamol, ineffective.
A 38-year-old man is reviewed by his general practitioner. He reports difficulties in maintaining positive relationships with colleagues.
On further questioning, it becomes clear that the man has a very strict value system and moral code. He is inflexible with respect to different beliefs and work practices and this inflexibility makes it difficult to form relationships with colleagues, collaborate or delegate.
What type of personality disorder best describes this patient?
Patients with obsessive-compulsive personality can be rigid with respect to morals, ethics and values and often are reluctant to surrender work to others
An obsessive-compulsive personality disorder is correct.
Patients with this personality disorder are very rigid with respect to morals, ethics and values and are reluctant to surrender work to others, as in this case. Other features are preoccupation with details, rules, lists and orders and perfectionism impairing the ability to complete tasks.
Which one of the following symptoms may indicate mania rather than hypomania?
(4)
Whilst criteria vary (e.g. ICD-10, DSM-5) the consistent difference between mania and hypomania is the presence of psychotic symptoms, e.g. auditory hallucinations.
Mania
- Lasts for at least 7 days - Causes severe functional impairment in social and work setting
- May require hospitalization due to risk of harm to self or others
- May present with psychotic symptoms
Which one of the following symptoms may indicate hypomania rather than mania?
(4)
hypomania
- A lesser version of mania
- Lasts for < 7 days, typically 3-4 days. Can be high functioning and does not impair functional capacity in social or work setting
- Unlikely to require hospitalization
- Does not exhibit any psychotic symptoms
A 64-year-old man is brought to the emergency department after being found at home in a state of self-neglect. It is suspected that he has a neurological event causing him to lose motor function. On examination, he is hypothermic and has a right-sided weakness.
On questioning, the patient states that he has not been able to take any of his regular medications, and since stopping them has begun to feel dizzy, restless, and has been experiencing electric shock sensations across his whole body.
Stopping which medication is most likely responsible for these symptoms?
Dizziness, electric shock sensations and anxiety are symptoms of SSRI discontinuation syndrome
A 25-year-old man with a history of schizophrenia is prescribed olanzapine.
Which adverse effects is he most likely to experience?
Weight gain is an extremely common adverse effect of atypical antipsychotics such as olanzapine
Adverse effects of atypical antipsychotics
- weight gain
- clozapine is associated with agranulocytosis (see below)
- hyperprolactinaemia
A 23-year-old man presents to his GP complaining of worsening headaches for the past few months. They are generalised and present most of the day. He also complains that he is more forgetful, forgetting appointments and telephone numbers. He attends with his partner who complains he has been more irritable in the past few months. He currently takes no medications and has no past medical history of note. He plays rugby for his local team but denies any major bumps to the head. He concedes that he has had a few rough matches this season.
What is the most likely diagnosis?
Post-concussive syndrome symptoms last more than three months after the initial injury.
They are often non-specific neurological symptoms.
The initial injury is often trivial and can be overlooked by patients.
This patient has a history of contact sports which he states included trauma.
A 40-year-old with known rheumatoid arthritis, established on sulfasalazine and regular paracetamol and ibuprofen, is seen by her GP with ongoing low mood. Non-pharmaceutical interventions have been trialled with limited improvement and now the patient reports they feel their depressive symptoms are worsening.
As such the GP decided to commence the patient on an antidepressant.
What agent would increase this patient’s risk of a GI bleed the most, therefore, warranting a protein pump inhibitor as cover?
SSRI + NSAID = GI bleeding risk - give a PPI
A 22-year-old woman is brought to the ED by the police with cuts on her forearms. The police officers advise that she was found in a public bathroom cutting her arms after getting into a physical fight with her girlfriend. The woman states that the argument started after her girlfriend refused to move in with her. She expresses that she hates her ‘now ex-girlfriend’ and doesn’t want anything to do with her.
This is the patient’s fourth attendance to the department for self-harm. She is otherwise well and takes fluoxetine daily - she says this is due to childhood trauma.
What is the most likely diagnosis?
Borderline (emotionally unstable) personality disorder is associated with a history of recurrent self-harm and intense interpersonal relationships that alternate between idealization and devaluation
A 35-year-old Afro-Caribbean male has a 4 year history of schizophrenia.
Due to his previous non-compliance, he was initiated on zuclopenthixol decanoate 200mg depot injection once a month.
Which of the following is a common side effect of this class of anti-psychotics?
Parkinsonian symptoms are a common occurrence with anti-psychotics.
Neuroleptic malignant syndrome is a rare but potentially life threatening side effect of anti-psychotics.
You are looking to prescribe an anti-depressant to a 74-year-old woman who has been complaining of low mood.
You know this patient has had problems with low appetite and maintaining her weight.
Which of the following psychiatric medications may help her appetite and mood?
Mirtazapine may be prescribed due to useful side effects (sedation and increased appetite)
A 40-year-old man presents to the hospital with his wife. He is restless, agitated, sweaty, and tremulous.
His wife provides a collateral history, explaining that the patient has been drinking at least half a bottle of vodka per day for many months.
However, he has cut his drinking down significantly over the past few days as he has run out of money with which to buy alcohol. His last alcoholic drink was around ten hours ago.
What drug would be most appropriate to manage this man’s condition?
This man is presenting with acute alcohol withdrawal. Long-term use of alcohol leads to upregulation of excitatory glutamate receptors and downregulation of GABA receptors. If the patient stops drinking alcohol suddenly, there is an excess of excitatory action, and the patient will present with symptoms of an overactive sympathetic nervous system. This is the case in this patient, who is restless, sweaty, tremulous, and agitated. Symptoms of withdrawal can develop as soon as 6-12 hours after the last drink. Patients in alcohol withdrawal are at risk of seizures and delirium tremens. Long-acting benzodiazepines (which potentiate the action of GABA) are given to mitigate this risk, either in a fixed-dose decreasing regimen as required per the patient’s symptoms. Examples of long-acting benzodiazepines include chlordiazepoxide or diazepam.
A 53-year-old gentleman presents to the GP surgery with constipation which has been ongoing for many years.
He reports not having opened his bowels for ten days.
He has a past medical history of atrial fibrillation, type II diabetes mellitus, gastro-oesophageal reflux disease and paranoid schizophrenia.
His medication includes apixaban, clozapine, digoxin, metformin and lansoprazole.
On examination, he has a firm, non-tender abdomen, and is fecally impacted on PR examination.
Which of the above medication is likely to be contributing to his chronic constipation?
One of the most common side effects of clozapine is constipation/intestinal obstruction
Which score is used to measure depression?
Patient health questionnaire-9 (PHQ-9) is used by GP’s as a tool to characterise severity of depression:
0-4 no depression identified
5-9 mild depression
10-14 moderate depression
15-19 moderately severe depression
20-27 severe depression
Angela is a 32-year-old doctor who you referred to the mental health team with suspected bipolar disorder. The psychiatrist has written to you to confirm a diagnosis of bipolar disorder and the commencement of lithium. Her levels have been monitored and she is now stable on treatment, therefore they have requested that you take over the monitoring.
You call Angela and advise that she will need her lithium levels. Angela remembers that it is important that she has these tests at a certain time related to her medication, but cannot remember when.
How would you advise her medication levels to be checked?
Blood test 12 hours post dose every 3 months
NICE advises the following with regard to lithium monitoring:
‘Lithium levels are normally measured one week after starting treatment, one week after every dose change, and 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.’
Which medication used in mental health is known to cause Hyponatraemia?
SSRIs are associated with hyponatraemia
Which class of drug have the Medicines and Healthcare products Regulatory Agency warned may be associated with an increased risk of venous thromboembolism in elderly patients?
Antipsychotics in the elderly - increased risk of stroke and VTE
A 32-year-old woman is brought to the emergency department with reduced level of consciousness.
She is found to have a blood sugar of 1.2 and is treated appropriately.
The paramedics say she was lying beside an insulin syringe when they found her, despite her not having diabetes.
This is the third time this has happened, and the woman is not suicidal.
What condition does this woman have?
Purposefully causing symptoms, for example a diabetic taking too much insulin to cause hypos, is an example of Munchausen’s syndrome
A 45-year-old female complains of lower back pain, constipation, headaches, low mood, and difficulty concentrating.
Her presentation is likely due to which of medication?
Long-term lithium use can result in hyperparathyroidism and resultant hypercalcaemia
