General Adult Psychiatry Flashcards
Comparing depot formulations which induces more EPSEs Haloperidol, Zuclopenthixol or Flupenthixol?
Zuclopenthixol - good symptom control but higher potency to cause EPSEs
Do depot antipsychotics have a higher risk of NMS?
No - the risk of tardive dyskinesia is also the same for oral preparations of the same drug
In the context of schizophrenia which antipsychotic drug has the best anti-suicide properties?
Clozapine - indirect evidence for SGAs but no direct longitudinal studies
D-cyloserine has been used as an add-on for the treatment of?
Schizophrenia/psychosis
it is a partial agonist at the glycine site of NMDA receptor and there is some evidence to suggest it can treat negative symptoms
Name some findings from the national epidemiological survey of alcohol and related conditions (NESARC) with respect to depression?
- Highest risk of depression is age > 30
- Mean number of episodes in patients with lifetime MDD is 5
- Longest duration was 24 weeks per episode
N.b studies have found the prevalence of depression is changing - point prevalence in NSEARC increased from 3.3% to 7% (lifetime prevalence 13%)
In what percentage does the diagnosis of depression eventually change (Kessing 2005)?
56%
- 16% to schizophrenia
- PD 9%
- Neurotic stress and somatoform disorders 8%
- Bipolar Disorders 8%
How long does depressive episode last treated vs untreated?
Untreated 6 - 13 months
Treated 3 months
What is the risk of recurrence in depression?
50% will have no future episodes
50% will have a recurrence < 5 years
If 2 episodes risk of recurrence is 70%
If 3 episodes risk of recurrence is 80-95%
For depression define response, recovery, relapse, remission and recurrence
Response is a decrease in symptoms from at least 50%
- partial response is a decrease from 26-49%
If no detectable symptoms and continue to do so after the natural period of a treated depressive episode (3 months) - HAMD < 7 this is termed remission
If this is maintained for 6 months - this is termed recovery
Return of symptoms within the 6 months is called a relapse
Return of symptoms after this period is a new episode and called recurrence
Do males or female relapse more for depression?
Females
For mixed depression and anxiety what do NICE advocate treating first?
Depression
When may SSRIs be continued for at least 2 years after the episode?
If > 2 prior episodes in recent past or if residual symptoms are present
In depression when lithium augmentation in combination with an anti-depressant is tried and a good response elicited how long should this be continued?
At least 6 months of both
What is NNT of anti-depressants for response/remission in short term trials (12-14 weeks)
Response 4-5
Remission 6-7
Briefly outline the stepped care approach to treatment by NICE?
Primary care and general hospitals - recognition for assessment and screening
Treatment of mild depression in primary care
- Self-guided CBT
- Watchful waiting
- Self-help
- Computerised CBT
- Exercise
- Brief psychological therapies
Treatment of moderate-severe depression
- Medication use
- Psychosocial support
- CBT - alone or in combination
Specialist treatment
- Medication
- Complex psychotherapies
- Combined treatments
Inpatient treatment
- Risk management
- ECT/combined treatments
For depression outline the acute, continuation and maintenance phases?
Acute - stabilisation of symptoms up to 3 months (aim for remission)
Continuation phase - 6-12 months (recovery begins at 6 months if symptom free). It covers the natural untreated course)
Maintenance phase - prevents recurrence - treatment dependent on risk factors and probability
Outline the levels in STARD
Level 1 - Citalopram encouraged to continue 12 weeks
Level 2 - if no remission at 12 weeks in level 1 randomised to the following based on preference to switch, augment or combine:
- Switch (Buproprion, Sertraline, Venlafaxine)
- Switch to CBT
- Augment Citalopram with (Bupropion, Buspirone)
- Combine Citalopram with CBT
Level 3 - if no remission at 12 weeks in level 2 randomised to:
- Switch to Mirtazapine, Nortriptyline
- Augment level 2with Lithium or thyroid
Level 4: no remission after 12 weeks in level choose to:
- Switch to Tranylcypromine or Nortryptyline
- Combine Mirtazapine with Venlafaxine
Name some pertinent findings from STARD?
Cumulative response was 67% after 4 steps
50% symptom free after 2 levels
Switch within and to different class anti-D from SSRI no difference statistically
No statistical differences between level 3 and level 4 treatments
Which anti-D classes and examples within class are most toxic in overdose?
From high to low mortality risk:
TCAs - dosulepsin and doxepin
Mirtazapine / Venlafaxine
SSRI - Citalopram
What are the 5As that can result in TRD?
Alcoholism
Adequate anti-D dose
Adherence
Axis 2 disorders
Alternate diagnosis
How does agomelatine work?
5HT2c antagonist - works as Serotonin works to drive GABAergic interneurons that tonically inhibit dopaminergic and noradrenergic circuits in the PFC
Agomelatine stops this inhibition
What does activated charcoal absorb poorly and effectively?
Effectively:
- TCAs
- Paracetamol
- Aspirin
- Theophylline
- Aspirin
- Barbiturates
Not effectively
- Lithium
- Alcohol
- Magnesium
- Potassium
- Sodium
- Acids
- Alkalis
Works well with non-polar poorly water soluble organic toxins
Contraindications for charcoal:
- Unprotected airway
- GI perf
- If endoscopy to be attempted
- If charcoal won’t absorb the item
Outline some considerations with St Johns wart?
Inducer of CYP450
- There is no identified therapeutic dose
- Similar AE to placebo in trials but interactions and can cause serotonin syndrome
- Cochrane evidence showed benefit for mild/moderate depression
Which condition is most associated with rapid cycling bipolar disorder?
Hypothyroidism
What is the prevalence of Bipolar Disorder as per the NCS-replication?
BD-1 1%
BD-2 1.1%
These are lifetime prevalences
The mean age of onset of BP-I was 18.2 whereas for BP-II tit was 20 years
What is the median time for treated mania to resolve?
4-5 weeks
Name some features in bipolar disorder that females are more likely to experience than men?
Mixed episodes, rapid cycling and depressive symptoms
Outline the ICD-11 & DSM-V criteria for mania
At least 1 week of:
- Elevated, euphoric or expansive mood AND increased activity or subjective energy
With “several (ICD-11)” or “3 or more (DSM-V)” additional features:
- Pressure of speech
- Flight of ideas
- Increased self-esteem or grandiosity
- Decreased need for sleep
- Distractibility
- Impulsive or reckless behaviour
- Rapid changes among different mood states
- Increased sexual drive, sociability or goal directed activity
What is mood destabilisation?
The long term phenomenon where anti-depressants cause more mood episodes over time than what would have occurred in the natural course
- N.b anti-depressants can induce switching and mood destabilisation or one or the other
RF for switch:
- FHx of BPAD
- Exposure to multiple anti-D trials
- Initial illness beginning in adolescence or young adulthood
- Previous anti-depressant induced mania
How many episodes a year constitutes rapid cycling?
> /= 4 a year
If >/= 4 a month ultra-rapid cyclin
If a patient has switches on >/= 4 days a week termed ultra-ultra rapid or ultradian rapid cycling
How does treating de novo mania vary to mania already on a mood stabiliser?
De novo:
- Stop anti-D if on one
- Initiate an antipsychotic with rapid acting anti-manic effect (preferable options include haloperidol, olanzapine, quetiapine or risperidone)
- Adjunctive benzodiazepine
If on a mood stabiliser:
- Increase the dose (check levels if Lithium)
-If optimising levels is ineffective then add haloperidol, olanzapine, quetiapine or risperidone
- If severely ill during pregnancy or severely ill and patient preference consider ECT
Outline preference options for bipolar depression?
Olanzapine + Fluoxetine
Quetiapine
Lamotrigine
Outline some guidance/options for managing maintenance in bipolar disorder?
Consider after a single manic episode and BD-II with severe functional impairment
1st line - Lithium (responders typically have euphoric mania, full remission, no comorbidity, no psychotic features, fewer liftime episodes, mania-depression-euthymia course)
Valproate - protects against manic and depressive
Olanzapine - prevents manic > depressive
Quetiapine - especially if effective in acute phase
Carbamazepine less effective than lithium
Lamotrigine - prevents against depressive > manic
How does DSM-V define personality disorders?
A) Enduring pattern of inner experience or behaviour that deviates markedly from socio-cultural expectation and manifests in changes in:
- Cognition
- Affectivity
- Impulsivity
- Interpersonal functioning
B) Pervasive and inflexible and is demonstrated across a range of situations
C) Significant distress/loss of functioning
D) Pattern can be traced back to early adulthood
E) Not explained by another medical disorder
F) Not explained by medication or substance misuse
Describe the ICD-11 personality disorder criteria?
An enduring disturbance in aspects of the functioning of the self (self-worth, identity, view of self, capacity for self-direction) and/or interpersonal functioning (ability to form and maintain close and mutually satisfying relationships, ability to see others perspectives and ability to manage conflict)
Disturbance over an extended time > 2 years
The disturbance manifests in patterns of cognition, emotional expression, emotional experience and behaviour that is maladaptive (poorly regulated an inflexible)
Shows in a range of personal and social settings (i.e not just one role/social experience) though a particular setting may evoke it and not others
Causes distress or impairment in functioning (personal, social, occupational or educational)
Not explained by other medical condition, medication or substance misuse
Not developmentally appropriate and not explained by politico-cultural context
What are the 5 trait specifiers in ICD-11?
- Dissociality
- Detachment
- Anakastia
- Disinhibition
- Negative affectivity
N.B borderline pattern has been kept as a specifier
In DSM-V which PD cannot be diagnosed pre 18?
Anti-social
If on tamoxifen which anti-depressant would be helpful as thought to be safe?
Venlafaxine
Which sedatives are thought to be safe in hepatic impairment?
Oxazepam
Lorazepam
Zopiclone
Temezepam
Outline the incidence/prevalence of schizophrenia?
Incidence estimated at 15.2/100,000 person years (Kirkbride 2012)
Prevalence 0.4%, for all psychotic disorders 0.63% (lifetime prevalence at age 43) - roughly consistent with 1% lifetime prevalence.
In SPMM 4.6/1,000 point prevalence noted
N.B the above refer to UK rates - internationally prevalence estimated at 0.33% and incidence 0.2/1,000 person years
Rates are higher in urban areas, migrant populations and developed countries
How do the Iowa 500 and Bon Hospital study counteract pessimistic claims about recovery in schizophrenia?
In Iowas 500 - 46% improve or recover over follow up (average of 35 years)
In Bonn Hospital Study - 22% had complete remission, 43% had remission of psychosis only (follow up of 22.4 years)
What is simple schizophrenia as described by Eugene Bleuler?
Insidious onset of social withdrawal with prominent negative features (relative absence of hallucinations, delusions and thought disorder)
Outline the positive symptoms detailed in the PANSS scale?
Delusions
Conceptual disorganisation
Hallucinations
Excitement
Grandiosity
Suspiciousness/persecution
Hostility
n.b. negative symptoms include:
- blunted affect
- emotional withdrawal
- difficulty in abstract thinking
- stereotyped thinking
- lack of spontaneity and flow of conversation
- poor rapport
- social withdrawal
What is the risk of schizophrenia if you have one 1st degree relative with the condition vs both parents?
12-15%
Both parents 40-50%
MZ concordance is 46%
Sexual side effects with SSRIs are associated with what receptor action
5-HT2A stimulation
- therefore drugs which poses 5HT stimulation with 5-HT2A antagonism have less sexual side effects - namely Mirtazapine
Why may the BDI be preferable to the MADRS or SCAN?
Patient reported and acceptable less skilled training required
What do the most severe cases of serotonin syndrome involve?
MAO-I + SSRI
What was drop out from treatment more commonly associated with in the STAR-D
Higher perceived MH functioning, less education, younger age
Interestingly experience with > 1 episode of depression was associated with less drop out
Broadly outline some obstetric complications associated with schizophrenia?
- Growth related events - low birth weight, small for gestational age
- Peri-natal risk factors - perinatal induced hypertension, hypoxic events
- Hypoxic events e.g. premature rupture of membranes
Lewis-Murray scale has been specifically designed to measure obstetric complications during childbirth (OR from various studies are too low to be significant)
Name 4 features of psychoeducation
Briefing patients about the illness
Problem solving training
Communication training
Self-assertiveness training
What is the NNT of family therapy in relapse prevention of Schizophrenia?
6
Who devised social skills training and what are the 3 forms?
Bellack and Mueser
- Basic model - complex social interactions are broken down into steps, the individual has corrective learning and practices through role playing
- Social problem-solving model - address difficulties in information processing that are assumed to cause problems in social impairment
- Cognitive remediation model - targeting fundamental cognitive impairments like attention or planning that will aid cognitive processes and will be applied in social environments
Name some psychosocial interventions for schizophrenia?
CBT-P
Vocational rehabilitation
Family therapy
Social skills training
What proportion of patients relapse
a) Within 1 year of FEP irrespective of antipsychotic treatment?
b) Within 1 year of FEP if on placebo > antipsychotics
c) Within 1 year following five or more prior episodes (irrespective of antipsychotics)
d) Within 1 year following five or more prior episodes (on placebo)
a) 27%
b) 61%
c) 48%
d) 87%
Name some brain regions associated with OCD?
OFC, cingulate gyrus, striatum (caudate nucleus, putamen), globus pallidus , thalamus
It is proposed that this neuronal loop is involved in the pathophysiology - indeed lesions in this area and surgical treatments that disrupt the loop (cingulotomy, anterior capsulotomy, sub-caudate tractotomy) can treat symptoms.
What is the difference between acute stress reaction vs acute stress disorder?
Reaction < 3 days
Disorder 3 days - 1 month
Over this period and need to screen for PTSD
For acute stress reaction symptoms should typically dimish within 48hrs after removal of the stressor
If stressor is ongoing the symptoms should be greatly reduced by 1 month
In OCD what percentage change in Y-BOCS is indicative of a treatment response?
Reduction of 25-35% of pre-treatment score
What proportion of patients with restless leg syndrome have periodic limb movements during the night?
80-90%
Periodic limb movements is seen in 1/4 of middle aged individuals
How does URGE outline the symptoms of restless leg?
Urge to move legs
Rest worsens urge to move
Getting up relieves symptoms
Evening or night worsens symptoms
Disorders that mimic RLS have been excluded
Supportive criteria:
- 1st degree relative
- Periodic limb movements occuring during the night
What is the treatment for restless legs syndrome?
- alpha 2 delta calcium channel ligands (Gabapentin, pregabalin, enarcarbil)
- Dopamine agonists (Pramipexole, Ropinrole, Rotigotine)
In narcolepsy type 1 (with cataplexy) which neuropeptide is low?
Hypocretin type - 1 (orexin)
Loss of these neurons leads to lack of suppression of REM promoting neurons AND inactivity of wakefulness promoting neurons
This then respectively activates pathways that inhibit motor activity (sleep paralysis and cataplexy) and loss of muscle tone (drop attacks)
Outline some REM related and non-REM related parainsomnias?
REM related - REM sleep behaviour disorder, recurrent isolated sleep paralysis, nightmare disorder
Non-REM related (arousal related) - sleepwalking, sleep terrors, sleep eating disorder, confusional arousals
Other para-insomnias include exploding head syndrome, nocturnal enuresis, sleep related hypnic hallucinations
In psychiatric outpatient samples what cluster of personality disorders is most common?
Cluster C - 22%
Cluster B - 13%
Cluster A - 6%
Any PD - 46%
Name some groups of patients that may require lower doses of Clozapine?
Non-smokers
Female patients
On CYP50 inhibitor (SSRI)
Elderly
Is risk of neutropenia related to Clozapine dose?
NO
Can Clozapine be used alongside carbamazepine?
NO - both can cause agranular cytosis
Why should patients who have agranular cytosis (ANC < 0.5) attributable to Clozapine not be re-challenged?
As the second reaction is often more severe and acute than the first
Which drugs have RCT evidence to treat Clozapine induced hyper-salivation?
Amisulpride and hyoscine hydrobromide
Which anti-depressants may be more effective for psychotic depression (combining with an antipsychotic)
TCAs
In ICD-11 what are the BMI categories for anorexia?
Significantly low 14 - 18.5
Dangerously low < 14
If an individual develops tardive dyskinesia on an antipsychotic which would be the most acceptable step?
Switch to an antipsychotic with a lower propensity to cause TD
What is a neurovegetative symptom?
Symptoms associated with poor functioning of the nervous system such as fatigue, sleeping problems or poor energy
What is the prevalence of bulimia in the general population?
0.5 - 1%
The average suicide rate in the UK for the…
a) General population
b) MH service users
a) 1 in 10,000
b) 1 in 1,0000
Name some anti-depressants that are safe and some that should be avoided in hepatic impairment?
Sertraline
Paroxetine
Citalopram
Vortioxetine
Avoid: TCAs and MAOI
Name some risk factors for Agranulocytosis and neutropenia on Clozapine?
Agranulocytosis:
- Asian
- Increasing age
Neutropenia
- African-caribbean
- Low age
- Low baseline neutrophil count
The suicide rate in epilepsy is BLANK compared to the general population?
3 x higher
The rate of non-compliance due to forgetting to take the medication is?
10%
Name some scales that assess medication compliance?
DAI - Drug attitude inventory (attitudes and beliefs about medication compliance)
MARS - medication adherence rating scale (frequency and consistency of medication taking and factors that may influence it)
How does anaemia present in anorexia?
Normocytic and normochromic, it may be masked by plasma depletion
Can be accompanied by thrombocytopenia
Anaemia occurs in 1/3 patients
When does rapid cycling tend to occur in BPAD?
Late in the illness course, in some individuals may resolve within 2 years (50%)
What are the psychiatric risks of the anti-retroviral drug Efavirenz?
Mania and completed suicide
In STAR*D how many people responded to the first phase of Citalopram?
30%
Asthenic personality disorder also refers to?
Dependent personality disorder (it is the older term)
The lifetime prevalence of suicide in Schizophrenia is?
5.6%
What is the standardised mortality ratio in Schizophrenia?
2.58
The SMR for Schizophrenia is rising - n.b standardised mortality rates are generally declining in most nations which suggests that individuals with Schizophrenia aren’t accessing life prolonging interventions
How did Olanzapine outperform other “atypicals” in the CAITE study?
Through less dropouts
Overall the CAITE study did not find significant differences between first and second generation antipsychotic drugs in terms of efficacy/cost
What are the minimum effective doses of the follwing antipsychotics according to the Maudsley Prescribing Guidelines?
1) Olanzapine
2) Risperidone
3) Haloperidol
4) Amisupride
5) Sulpride
6) Aripiprazole
7) Chlorpromazine
8) Trifluperizine
FEP dose presented first, then in relapse of multi-episode:
1) 5mg, 7.5mg
2) 2mg, 4mg
3) 2mg, 4mg
4) 300mg, 400mg
5) 400mg, 800mg
6) 10mg, 10ng
7) 200mg, 300mg
8) 10mg, 15mg
Generally FEP may respond to lower doses
No clear evidence if maintenance needs lower dose than acute episode
What did the CAITE data indicate with “stayers” or “switches” especially with Olanzapine
“Stayers” had preferable outcomes than “switchers”
Name some antipsychotics helpful for managing aggression?
Clozapine > Olanzapine > Haloperidol
What is deficit Schizophrenia?
- Two of a) Restricted affect b) diminished emotional range c) diminished social drive d) diminished sense purpose e) curbing of interest
- Two or more of the features must be present in the prior 12 months and alway present during periods of clinical stability (chronic psychotic states) and may or may not be present in acute transient psychotic disorganisation
- Two of the factors are idiopathic rather than due to anxiety/depression, drug effects, positive symptoms etc
- Patient meets DSM-V diagnosis for schizophrenia
How do primary and secondary negative symptoms differ
Primary - intrinsic to Schizophrenia
Secondary - result of positive symptoms, medication, affective changes, environmental situation etc
Which antipsychotic may be helpful for negative symptoms?
Amisulpride (as per Maudsley guidelines)
- Olanzapine has some evidence
Other drugs…
- Also add on D-cycloserine
- Glycine
- Selegine
What did the Intersept study show regarding effective antipsychotics for preventing suicide in schizophrenia or schizoaffective disorder?
Clozapine outperformed Olanzapine (HR 0.76)
n.b hazard ratio is relative risk for a hazard event
What is the minimum period that individuals should continue an antipsychotic for after
a) FEP
b) Multi-episodes
a) 1-2 years
b) 5 years if not indefinitely
Which antipsychotic drugs may be less sedating?
Aripiprazole, Amisulpride, Haloperidol
Should patients have a lower dose in the maintenance period?
Not necessarily - use the minimum effective dose, often this is the same dose as was reached to treat the acute episode
What is the advised quickest dose escalation frequency for HDAT?
Not more than weekly
How many haloperidol resistant patients responded with Clozapine during 6 weeks?
30% (vs. 4% of Chlorpromazine)
Meltzer concluded that 20% may also respond within 3 months and 10-20% within 6 months
The plasma therapeutic level of Clozapine?
Unclear but advised to aim for 350-450ng/ml
What adjuncts have been studied to augment Clozapine?
- Lamotrigine - RCT showed improvement with positive symptoms and general psychopathology
- Risperidone - evidence if Risperidone dose around 4.5mg/day and Clozapine 475mg/day
- Amisulpride/Sulpride - high D2 blockade (Clozapine not thought to act via this)
- Fluoxetine - ?by CYP inhibition
In CAITE phase 2 study what was compared?
Efficacy pathway - if discontinuation < 18 months due to non-response Clozapine vs other atypicals
- Clozapine time to discontinuation was 3 x longer than other atypicals (Olanzapine, Risperidone, Quetiapine or Ziprasidone)
- Median time to discontinuation for Clozapine was 10 months
Tolerance pathway if couldn’t tolerate the medication:
- Here Olanzapine, Risperidone, Quetiapine and Ziprasidone were compared
- Olanzapine and Risperidone moderately more effective than Quetiapine and Ziprasidone
Describe the treatment of schizoaffective disorders?
Mood stabiliser:
- Carbamazepine has good efficacy for depressive subtype
- Carbamazepine/Lithium equally effective for manic subtype
Antipsychotics - in combination or as own as mood stabilising effect
Anti-depressant guidance is the same as BPAD
What does Wiljkstra meta-analysis for RCTs for psychotic depression show?
That no difference between anti-D and combination (antipsychotic + anti-D) in efficacy
Combination more effective than placebo
Monotherapy of anti-D = monotherapy of antipsychotic (with respect to efficacy)
NICe recommend combination with TCAs having some increased efficacy
Which anti-depressants have a low, moderate and high risk of seizures?
Low:
- SSRI
- Mirtazapine
Probably low:
- Agomelatine
- MAOIs
- Moclobemide
- Reboxetine
- Vortioxetine
Moderate:
- Venlafaxine
- Trazadone
- Lithium
High:
- TCA
- Buproprion
- Maprotiline
What is the most common anxiety disorder in the general population?
Specific phobia
If taken late in pregnancy what may there be a small risk of?
Persistent pulmonary hypertension
When switching from phenelzine to fluoxetine what is the minimum washout period?
2 weeks
What are the indications of adding Trazadone?
Insomnia
Adjunctive treatment for an anti-depressant
Name some add on treatments for sexual dysfunction for men/women?
Both men and women - Buproprion 150mg BD or Sidenafil
Men - Tadafinil
Having unusual beliefs or magical thinking that is not consistent with subcultural norms may point to…
Schizotypal disorder - note distress or impairment in social, family or personal functioning
Describe avoidant personality disorder
- Strong sensitivity to rejection or criticism
- May be socially withdrawn
- Need for strong guarantees of uncritical acceptance in relationships
- Avoid jobs with interpersonal contact
- View self as inferior
- Reluctance to take risks because of embarressment
- Social inhibition because of feelings of inadequacy
Outline some poor prognostic features for anorexia nervosa?
- Male sex
- Late onset
- Purging behaviours
- Psychiatric co-morbidity (OCD, substance misuse, cluster C personality disorder)
- Chronic course of illness/longer duration
- Anxiety when eating with others
What is the risk of relapse of BPAD post-partum?
67% - 40% quoted on MRCPsych
What proportion of men hospitalised for depression aged 30 may have their diagnosis changed to bipolar disorder at 5 years?
7-12%
Why were the subtypes of Schizophrenia removed from the ICD-11
Lack of prognostic validity
Lack of utility for treatment selection
Lack of diagnostic stability
How is osteoporosis treated in anorexia nervosa?
Increasing BMI > 19 - to reach regular menses
HRT, Bisphosphonates and OCP are ineffective
Osteoporosis itself is rarely reversible and treatment to increase weight is aimed to improve bone density/mass
How does facticious disorder and malignering differ?
Both involve intentional production of symptoms - in malingering there is secondary gain
What is the mean age of onset of GAD, OCD, social phobia and panic disorder?
GAD - 30 years
OCD - 20 years
Social phobia - 15 years
Panic disorder 22 - 25 years
Specific phobia 5-9 years
Research is showing the mean age of onset is decreasing
Describe the epidemiology of OCD
Point prevalence of 1-3% in adults, 1-2% children
Lifetime prevalence of 2-3%
4th most prevalent psychiatric disorder in epidemiological studies (behind phobias, alcohol disorders, and depression)
State some etiological factors thought to underlie OCD?
Dysfunction in basal ganglia - D2 antagonists (antipsychotics and Clozapine) can worsen symptoms in some patients
Paediatric autoimmune neuropsychiatric diseases associated with Streptococcal infection (PANDAS)
- Infection with Group beta-haemolytic streptoccus
- Symptoms temporally related to infection either through exacerbation or onset
- Onset 3 years - puberty
- Symptoms associated with neurological features hyperactivity, chorea movements or tics
- AntiDNAseB or ASO - a fraction may have auto-antibodies in the basal ganglia
Outline the treatment of OCD in children and adults?
Mild:
- Adults –> low intensity CBT (< 11 session) can be individual or group
- Children –> self-help in conjunction with support from parents
Moderate:
- Adults –> Either CBT including ERP OR SSRI (fluoxetine preferred)
- Children –> CBT including ERP
Severe:
- Adults –> CBT (inc. ERP) and SSRI (fluoxetine preferred)
- Children –> CBT (inc. ERP) and SSRI if they decline with treatment (Sertraline or Fluvoxamine preferred)
-
-
How long should anti-D be continued in OCD?
For 12 months if effective
In children Sertraline/Fluvoxamine favoured - Clomipramine second line
In adults Fluoxetine, Sertraline, Paroxetine, Fluvoxamine or Citalopram and again Clomipramine is second lineName
Name some second line options for OCD in adults?
Add in antipsychotic (low dose)
Combination SSRI + Clomiprazmine
Lamotrigine/Topiramate + SSRI
Acetylcystine + SSRI/Clomipramine
Is an internal/external locus of control more associated with the development of PTSD after a traumatic event?
External locus of control
What is the ICD-11 diagnostic criteria for PTSD?
- Exposure to an event of extremely threatening or horrifying nature (short lived or long lived. Includes natural disasters, sexual/physical assault, watching an assault/death/threat of others in unexpected way. Finding out the death of a loved one in a sudden, unexpected or violent way could be sufficient.
Accompanied by
1. Re-experiencing symptoms that the trauma is ongoing and present now to some extent - can be flashbacks, memories or dreams and are accompanied by strong emotions or physical symptoms (note reflecting and rumination on their own are not enough to meet diagnostic threshold)
- Avoidance of reminders - active internal/external avoidance
- Persistent perceptions of heightened sense of stress - hyper-vigilance or increased startle reaction
Associated symptoms:
- General dysphoria, suicidal ideation/thoughts/behaviour, use of alcohol/substances to manage symptoms, social withdrawal, panic or obessions/compulsions
- Cognitions - shame/guilt/hopelessness
Onset:
- Typically symptoms present within 3 months of trauma but can be years
- Nearly 50% have a complete recovery within 3 months of onset of symptoms
Name some pathophysiological features associated with PTSD?
1.5 F : 1 males
- Hypocortisolaemia
- Dysfunction in amygdala and hippocampus
What is the management of PTSD in children and adults?
Children:
- TF-CBT if severe symptoms or watchful waiting
- If presents 3 months after trauma EMDR can be offered if TF-CBT ineffective or not engaged
Adults:
- < 1 month and mild symptoms - watch and wait
- < 1 month and severe symptoms - TF-CBT
- > 3 months - EMDR or TF-CBT
- Can also offer supportive computerised focussed CBT
If there is 4 consecutive nights sleep disturbance can offer non-benzodiazpine sleeping tablet
n.b TF-CBT is 8 - 12 sessions (may be 5 if within a month of symptoms) aims to do cognitive restructuring
Which anti-D may be used for PTSD?
Venlafaxine or Sertraline
Describe features of adjustment disorder and how it differs to PTSD?
Reaction to psychosocial stressor that emerges within 1 month of the stressor and resolves within 6 months of the stressor/its consequences
Symptoms include preoccupation, rumination, worry and distressing thoughts about the consequences of the stressor
Failure to adapt leads to loss of functioning or functioning with significant effort
n.b unlike PTSD there are no remembering symptoms
What additional features are needed to meet the diagnosis of complex PTSD?
- 3 criteria or re-experiencing, heightened threat and avoidance are met
Additionally:
- Difficulties in affect regulation
- Negative beliefs about oneself - diminished or feeling their worthless
- Inability to sustain relationships or feel close to others
Often the events in complex trauma are repetitive and where escape is difficult or impossible
How long does an acute stress reaction last?
Typically a few days after the stressor
If symptoms have not “greatly” reduced by 1 months - consideration of PTSD is needed
Outline the diagnostic criteria for anorexia nervosa?
Significantly low body weight under developmentally expected norms:
- BMI < 18.5
- Rapid weight loss - 20% in 6 months
- BMI < 5th percentile for children and adults
- Low body weight not explained by absence of food or another medical condition
- Behaviours aimed to maintain or reach an abnormally low body weight - can be restrictive eating, purging behaviours or increased energy consumption
- Excessive preoccupation with body weight/shape - low body weight/shape is central to the persons evaluation of themselves or the persons perception of body weight/shape is inaccurate as normal/excessive
Specifiers:
- Restrictive pattern - restrictive eating alone or in combo with increased energy expenditure
- Binge-purge pattern
Which ilicit drugs interact with G-coupled receptors?
Opiods, cannabis, GHB
Name the masango risk factors for completed suicide?
Male gender
Age - Men > 45 years, Women > 55 years
Poor physical health - co-morbidity
Lower social class
Substance misuse
Not married
Unemployed
Personality factors - perfectionism/pessimism/rigid thinking
Previous suicide attempt/self-harming behaviour
What is the sex ratio of men:women for BPD?
1M : 3F
If an anti-depressant is stopped on immediate recovery of a depressive episode what percentage experience a relapse within 3-6 months?
50%
What drugs are associated with rapid cycling?
Propanolol, levo-dopa or cyproheptadine
Why is mitral valve prolapse common in individuals with eating disorders?
Loss of cardiac tissue but retained valve size
What are the risks of hyperprolactinaemia and which patients should not be prescribed an antipsychotic with a high risk for Hyperprolactinaemia
Risks
- Breast cancer
- Osteoporosis
Do not prescribe an antipsychotic with a tendency for hyperprolactinaemia to a patient with:
- < 25 years (before peak bone mass)
- Osteoporosis
- Hormone dependent cancer
- Young women
How should hyperprolactinaemia be managed in patients on antipsychotic medication?
Refer for tests to rule out hyperprolactinaemia
- If effective and tolerated (not symptomatic high prolactin) warn about risks and make a joint decision with the patient
- If symptomatic try to switch to antipsychotic less likely to cause hyperprolactinaemia
- If switching is not an option add on Aripiprazole 5mg
- Can also add on dopamine agonists (Bromocriptine or Amantadine) or metformin
How should Bipolar Disorder prophylaxis be managed in pregnancy?
If on Lithium, Vaproate, Lamotrigine, Carbamazepine - ideally switch to an antipsychotic
For Lithium - gradual dose reduction over 4 weeks then start an antipsychotic
If the women wishes to continue taking lithium monitor monthly then weekly from 36 weeks onwards
Which anti-depressant does NICE recommend prescribing to individuals with co-morbid physical health issues and why?
Citalopram as it is a weaker inhibitor of CYP 450 enzymes
What is the diagnostic criteria for GAD according ICD-11?
Marked symptoms of anxiety that manifests as:
- Free-floating general apprehension
- Worry about several topics
Accompanied by:
- Sleeping disturbance
- Irritability
- Muscular tension
- Difficulty concentrating
- Nervousness or being on edge
- Autonomic symptoms - abdominal discomfort, nausea, dry mouth, shaking/trembling, palpitations
Needs to be present for more days than not for a period of several months
Outline NICE guidelines stepped care for treatment of GAD?
Mild:
- Education and monitoring
Mild but no response to above:
- Individual self-help
- Individual guided self-help
- Psychoeducation groups based on CBT
Moderate:
- Individual high intensity psychological therapy (CBT or applied relaxation) OR
- Drug therapy - SSRI/SNRI
Severe - no response to above or self-harm/suicide risks:
- Specialist treatment with complex interventions of psychotherapy and drug treatments
- Input from multi-agency teams, crisis teams or day hospitals
n.b BDZ not used and if so not beyond 2-4 weeks of crisis period
- anti-D continue for 1 year if successful
- If SSRI/SNRI not tolerated can offer pregabalin
What is the 12-month and lifetime prevalence of GAD? (Kesser 2005 - MRCPsych mentor)
12-month 3.1%, lifetime 5%
What is the 12-month and lifetime prevalence of social phobia? (Kesser 2005 - MRCPsych mentor)
12-month - 6.8%
Lifetime - 12.1%
What is the ICD-11 diagnostic criteria for panic attacks?
- Recurrent panic attacks - sudden episodes of fear or apprehension with several accompanying symptoms
- At least some of the panic attacks are “unexpected” i.e. not occuring in predictable places/contexts/scenarios - out of the blue
- There is a ongoing worry about their recurrence or significance (i.e. does it indicate a medical disorder) or there is change in behaviour aimed at preventing further panic attacks - i.e. not exercising
- Not explained by another medical/mental health condition, substance misuse/withdrawl
- Impairment with functioning or functioning with effort
n.b over time individuals may change their behaviour to avoid cues for panic attacks - if this becomes severe enough and with added fear of those environments they may meet criteria for agoraphobia
Which SSRI may be chosen for BDD?
Fluoxetine How m
The NICE guidelines for panic disorder recommend?
Mild - moderate:
- Individual non-facilitated self-help
- Individual facilitated self-help
Moderate - severe:
- CBT
- Anti-depressant if not benefitted from CBT, long-standing condition or declined psychotherapy
How much may the risk of Schizophrenia be increased in those who smoke cannabis during adolescence?
2-fold if smoke in adolescence in general
4-fold if smoke in early adolescence
Which anti-depressants may be helpful for premature ejaculation?
SSRIs - effects may be noticed within days but often peak 1-2 weeks after starting medication
The simpson-angus scale measures….
Drug induced parkinsonism inc. bradykinesia and tremor
How should patients on the COCP have their treatment tailored if taking carbamazepine?
They should take at least 50mcg of oestrogen or try a non-hormonal method
What medication may result in increased impulsivity in BPD?
Benzodiazepines
Does sodium valproate have anti-manic properties?
Yes
Is amisulpride associated with a dry mouth?
No
Which TCA is not safe in breast feeding?
Doxepin
- Imipramine and Nortriptyline are safe
When should Lithium levels be checked?
5-7 days after starting to check range
Once range has been stabilised 3 months for the first year than 6 monthly after
If - age > 65, last level 0.8 mmol/L or above, poor compliance, taking drugs known to interact then 3 monthly levels continue
(BNF) Monitor body-weight or BMI, serum electrolytes, eGFR, and thyroid function every 6 months during treatment
Which anti-depressant interacts with theophylline to elevate levels?
Fluvoxamine - through inhibition of CYP1A2
Which anti-depressant may increase the seizure risk with Clozapine if co-prescribed?
Fluoxetine - through inhibition of CYP2D6
n.b Clozapine is metabolised by CYP2D6, CYP1A2, CYP3A4
What is the incidence of puerpal psychosis
1 - 2 / 1,000
In the AESOP study the incidence of schizophrenia for Caribbean is increased by what factor?
9
Name some sleep changes that happen in Schizophrenia
- Decreased REM latency
- Decreased slow wave sleep
Which antipsychotics should not be used to augment with Clozapine
Olanzapine
Sertindole
Pimozide
What are the common clinical symptoms in Clozapine associated myocarditis?
Dyspnoea (90%)
Palpitations/arrhythmias
Elevated cardiac biomarkers
Prodromal flu
Tachycardia
Leucocytosis
Chest pain (25%)
Out the risks of developing a schizophrenia according to the Gottesman data
a) General population
b) 1st cousin
c) Grandchildren
d) Parents
e) Siblings
f) Children
g) Fraternal twins
e) Identical twins
General population 1%
First cousin 2%
Grandchildren 5%
Parents 6%
Siblings 9%
Children 13%
Fraternal twins 17%
Identical twins 48%
For vigabatrin is visual loss permanent?
Yes - it can cause permanent bilateral concentric visual impairment that can also affect the retina affecting acuity
The risk increases with higher doses and cumulative exposure and can worsen despite continuation
Following discharge from hospital what percentage of patients will be non-compliant at
- 10 days
- 12 months
- 24 months
(according to 12th edition of the Maudsley Guidelines)
25% at ten days
50% at one year
75% at 2 years
Name some adverse effects of St Johns Wart?
- Macular degeneration (may contribute)
- Hypomania (may contribute)
Dry mouth
Nausea
Constipation
Fatigue
Dizziness
Headache
Restlessness
How does NOS work?
NMDA antagonism
Which anti-psychotic has the best evidence base in adults with HIV?
Risperidone
What is the male:female ratio for autism?
5:1
For panic disorder if a trial of an SSRI has been effective does NICE recommend a switch within or between anti-D class?
Between anti-D class
Which anti-D are high risk for seizures?
TCAs, Buproprion, Maprotiline
Moderate risk: Lithium, Trazadone, Venlafaxine
Low risk: SSRI, Mirtazapine, Duloxetine
Probably low risk:
Agomelatine
MAOIs
Moclobemide
Reboxetine
Vortioxetine
Which SSRI is licensed for Bulimia?
Fluoxetine
If a patient experiences a seizure on Clozapine what should be done?
Withhold for a day - re-start at half the dose and introduce an AED
Outline the diagnostic criteria for PMDD as per DSM-V
At least 5 of following 11 symptoms (inc. 1 of 1 - 4):
- Depressed mood
- Marked anxiety
- Marked affective lability
- Marked anger or irritability
- Anhedonia
- Difficulty concentrating
- Lethargy, easy tiredness or loss of energy
- Change in appetite
- Sleep changes
- Feeling out of control
11 Physical symptoms - breast tenderness or swelling, headaches, joint/muscle pains, bloating or weight gain
How is PMDD treated?
Mild - lifestyle changes, CVT, exercise, dietary regulation
Severe - SSRIs (Fluoxetine preferred) but also Comipramine or Venlafaxine.
Can be intermittently dosed (2 weeks prior to menses) or continuous
Continuous dosing more effective for somatic symptoms
What did the SADHART study find?
No difference in safety noted between placebo and Sertraline arms (assessed QT prolongation, LVEF, increase in premature ventricular contraction). There was a non-significant reduction in composite end point (MI or CHD death)
No difference in depression status between groups.
Comparative trials for CBT for depression post-MI (ENRICHED) or medication (MIND-IT) showed reductions in depression but not cardiac events
What symptoms may be useful to indicate depression in a dying patient?
- Pervasive global anhedonia
May be treated with SSRI, low dose Amitriptyline (esp if neuropathic pain), lofepramine and rapid-acting psychotimulants
For renal impairment which Benzodiazepines should be avoided?
Diazepam - while its half-life is unchanged its metabolite desmethydiazepam may accumulate and cause excessive sedation
Lorazepam in ESRF the half life is increased from 8-25 hours to 32-72 hours - if low renal function cut dose by 50%
Which anti-depressants should have their dose changes in renal impairment?
Paroxetine - reduce dose as its half-life is significantly increased in renal impairment
Fluoxetine, Fluvoxamine are safe to be given
Sertraline manufacturers do not recommend it be given in renal impairment
Which antipsychotics should be avoided in renal impairment?
Amisulpride
- For risperidone itself and its metabolite 9-hydroxy-risperidone are substantially renally excreted so the half-life is prolonged
- Haloperidol to consider if sedation/postural hypotension
How do apperceptive and associative visual agnosia differ?
Apperceptive visual agnosia - inability to name or draw items. Caused by bilateral lesions in the visual association areas
Associative visual agnosia an individual can still draw the item but cannot name/use them - bilateral lesion in the medial occipitotemporal region
Is chronic fatigue syndrome more common in men or women?
Women - 1:3 ratio
n.b the peak age of onset is 20-45 years (mean aorund 29 - 36 years)
Do sleep terrors occur in REM or NREM sleep?
NREM sleep - typically in phase 3 sleep
Last 5-10 minutes and the individual has no memory of them.
There is increased autonomic activity including tachycardia, tachypnoea, diaphoresis, flushed face, dilated pupils and increased muscle tone
Which anti-depressants may be most effective/safe to use in post-stroke depression?
Escitalopram/citalopram - generally thought to interact the least with Warfarin whilst being effective at treating low mood
(Maudsley Prescribing Guidelines)
Name some maternal risk factors associated with ADHD in the child?
Smoking
Obesity
Pre-eclampsia
Hypertension
Paracetamol exposure has been implicated too
Which anti-depressant may have anti-emetic properties?
Mirtazapine - through 5HT3 antagonism (this is how Ondansetron exhibits its effects)
Which encephalitis may cause amnesia?
Herpes Simplex Encephalitis - due to affecting the temporal lobes
Other neuropsychiatric symptoms include Kluver Bucy Syndrome, personality changes and focal impaired awareness seizures
Why may sertraline be recommended for depression in pregnancy?
Least placental exposure and lowest risk of persistent pulmonary hypertension of the newborn
Is relapse of schizophrenia or bipolar more common after pregnancy?
Bipolar disorder - 67%
Schizophrenia - may only be 16% at 12 months
If an individual has a past history of depression what should they be offered ahead of treatment with interferon beta?
A prophylactic anti-depressant
What are the rates of baby blues post-partum?
3 in 4
What is the prognosis of MS?
- 20-30% relapsing and remitting but not seriously disabled
- 60% secondary progressive (period of progression following relapses and remissions)
- 5-10% show a steady progression of disability
Outline some treatments available for MS?
- Steroids
- Glatiramer Acetate - neuroprotective and immunomoduator to reduce frequency of relapses
Name some ocular signs for MS?
- Optic neuritis
- Intranuclear opthalmaplegia (nystagmus and/or diplopia due to a brainstem problem)
- Ocular motor craniopathy (6th nerve palsy)
What is the prevalence of depression in MS?
25-50%
Like other depressive episodes SSRIs are first line pharmacological treatment
Some evidence to suggest that ECT may trigger relapses - higher risk if active brain lesions?
Other conditions that can arise include mania an psychosis
These can arise as complications of treatment (interferon beta - depression, steroids, baclofen, dantrolene and tizanidine)
How is pathological laughing treated in MS?
Amitriptyline or SSRIs (Fluoxetine, Citalopram, Sertraline)
Also known as pseudo bulbar affect
Which anti-depressants may be chosen for post-stroke depression?
If on warfarin or a DOAC - citalopram/escitalopram
Fluoxetine, Paroxetine and Citalopram otherwise
Nortryptiline not thought to increase risk of bleeding
What is the prevalence of depression post stroke?
30-40%
- lesions in left hemisphere basal ganglia thought to play a role
Which antipsychotics are moderate - high risk for seizures?
Low risk
- Sulpride/Amisulpride
- Aripiprazole
- Ziprasidone
- High potency FGAs (e.g. fluphenazine, haloperidol, trifluoperazines, flupentixol)
- Risperidone
Probably low risk - Asenapine and Lurasidone
Moderate:
- Olanzapine
- Quetiapine
High risk
- Clozapine
High risk avoid:
- Low potency FGA (e.g. chlorpromazine)
- Loxapine
- Zotepine
- Depot antipsychotics
Which antipsychotics may be safe/effective for parkinson’s psychotic symptoms?
Quetiapine - low dose
Clozapine
Avoid risperidone and other typical agents
Approach to treating PD psychosis:
1. Exclude causes of delirium
- Withdraw antiparkinsonian medication regime- anticholinergics, selegiline, dopamine agonists, COMT inhibitors.
L-dopa therapy, only in lowest dose possible to maintain motor function (motion/emotion dilemma)
3. Antipsychotic therapy or cholinesterase inhibitors?
4. Other options – supportive treatment, ECT
5. Pimavanserin 5HT2A inverse agonist - (Cummings Lancet 2013)
What is the inheritance of Huntington’s disease?
Autosomal dominant
Name some diagnostic tests for WIlson’s disease?
Reduced serum copper
Reduced caeruloplasmin
Increased 24hr copper excretion
What is the treatment for Wilson’s disease?
Copper chelating agents
- Penicillamine (chelates copper) has been the traditional first-line treatment
- Trientine hydrochloride is an alternative chelating agent which may become first-line treatment in the future
- Tetrathiomolybdate is a newer agent that is currently under investigation
Outline the diagnostic criteria for transient global amnsesia?
- Witnessed from a capable observer
- Clear-cut anterograde amnesia
- Clouding of consciousness and personal identity must be absent - (cognitive impairment is limited to amnesia - no aphasia or apraxia)
- No focal neurological symptoms and no significant neurological signs after
- Epileptic features absent
- Resolves < 24hrs
- Recent head injury or active epilepsy (on medication or seizures in last 2 years) are excluded
n.b thought to be due to hypoperfusion of temporal and parietotemporal regions - L hemisphere.
Most completely improve but recurrence is high
What is Herpes encephalitis typically caused by?
HSV-1
For immunocomprimised may be HSV-2 or also HHV-6/7
Causes limbic encephalitis - confusion, memory impairment and seizures. 70% may show psychiatric disturbances including acute confusion, depression and psychosis - fever is common but invariable
Imaging (MRI preferable but can show on CT) - swelling in temporal lobes - can lead to elevated ICP
EEG shows non-specific diffuse slowing
CSF - elevated protein and lymphocytosis - gold standard is CSF PCR for herpes viruses
Treated with IV aciclovir - reduces case fatality by 20-30% untreated it is 70%
If bilateral temporal damage can cause Kluver Bucy syndrome - hyperphagia, visual agnosia, inappropriate sexual behaviour - carbamazepine may be used to control symptoms
Define mild, moderate and severe TBI with regards to PTA, GCS and LOC
Mild
- LOC: < 30 minutes
- GCS: 13 or over
- PTA: < or equal to 24hrs
Moderate:
- LOC: 30 mins - 24hrs
- PTA: 2 days - 7 days
- GCS: 9 - 12
Severe:
- LOC > 24hrs
- PTA > 7 days
- GCS < 9
Note PTA is anterograde it starts from the period of the injury and until normal memory resumes
Outline some parasomnias according to which phase of sleep they occur in?
NREM sleep:
- Confusional arousals
- Sleepwalking
- Sleep terrors
REM sleep parasomnias:
- REM sleep behavioural disorder
- Sleep paralysis
- Nightmares
Sleep-wake transition disorders
- Sleep starts
- Sleep talking
In REM sleep disorder what does polysomnography demonstrate?
REM sleep without dystonia
In REM sleep behavioural disorder - dreams are acted out as complex behaviours. It can occur idiopathically or in disorders such as Parkinson’s disease, dementia lewy body, multiple system atrophy and GBS.
Treatment is to make the sleep environment safe and clonazepam has been used
When is sleep walking more common?
In first 3rd of the night - typically occurs in stage 3-4 sleep
Name some precipitants for restless leg syndrome?
Iron deficiency (anaemia. renal insufficiency, pregnancy)
Peripheral neuropathy
Use of sedating anti-histamines
Use of central active dopamine receptor antagonist - antipsychotics/metoclopramide, antidepressants
Ratio of RLS is 1M : 2F
How does periodic limb movement disorder differ from restless leg syndrome?
PLMD is an asleep phenomenon whereas RLS is an awake phenomenon
PLMD requires polysomnography evidence - sleep hygiene is the main treatment
How does NICE advise a diagnosis of CFS be made?
Symptoms for 3 months not explainable by another condition:
- Fatigue - that is not refreshed by rest or explained by physical/emotional/social exertion
- Worsening of symptoms after the exertion that tend to be 1. not proportional to the activity 2. delayed in onset by hours - days 3. require significant time to recovery
- Cognitive difficulties “brain fog”
Other criteria namely The Centers for Disease Control and Prevention criteria is severe fatigue for 6 months with additional 4 other symptoms
Outline the treatment for chronic fatigue syndrome?
Self-help management strategies - “pacing” (managing their activity levels to stay within their limit with support from a health professional)
Personalised physical activity (overseen by CFS specialist or physiotherapist) - aim is to establish a pattern of activity that does not worsen their symptoms then to go below this and maintain it for a period of time before considering increases/decreases as needed to maximise physical capacity
CBT
Note graded exposure therapy is no longer recommended by NICE
Name some subcortical dementias?
Parkinson’s disease dementia
Normal pressure hydrocephalus
HIV dementia - develops quickly over weeks to months (rapidly progressing dementia)
Vascular cognitive impairment
Huntington’s disease - slowing, apathy and amnesia
In subcortical dementias affective changes, slow mental processing overshadow cognitive changes. Gait disturbances are characteristic
Cortical dementias differ as the patient is alert, attentive and ambulatory e.g. Alzheimers with aphasia, agnosia, apraxia
What is the most common behavioural change seen in Huntington’s disease
Lack of initiative
Other changes include emotional blunting, poor self-care, self-centredness, inflexibility, irritability and verbal outbursts
Is the risk of lamotrigine in pregnancy equivalent to valproate or carbamazepine?
No - lamotrigine has lower risks
Associated with autism - NICE advise checking levels as these can vary substantially during pregnancy
Why may nortriptyline and desipramine be preferred in pregnancy?
- Less hypotensive
- Less anti-cholinergic side effects
Paroxetine in pregnancy can lead to?
ASD and VSD in 1st trimester
Neonatal withdrawal in 3rd trimester
What are the perinatal risks of Carbamazepine?
0.5 - 1% risk of spina bifida, craniofacial anomalies, growth retardation, decreased head circumference
In some research 26% finger nail hypoplasia, 20% developmental delay, 11% craniofacial defects
What is the risk of any birth defect for sodium valproate?
7.2%
The risk is dose related, and mostly seen 17 to 30 days post conception and increased if FHx of birth defects
Can cause foetal distress, growth retardation, hepatotoxicity and congenital anomalies, limb defects, heart defects (VSD and pulmonary stenosis), urogenital malformations, low birth weight and psychomotor slowness
Can also cause neurological problems - hyperexcitability
Low IQ - 30% needed SEN support in schools
What birth defect is lamotrigine associated with?
Cleft palate - 3.2% risk of malformations from lamotrigine (across the board)
If Lithium is taken in pregnancy high quality USS and echocardiogram of infant should be performed when?
11 - 14 weeks (Maudsley guidelines for treating physical health conditions)
SPMM state at 6 and 18 weeks
The risk of mental illness is increased post-partum - which period is the highest risk?
First 3 months
What is the prevalence of PMDD in women of reproductive age?
2 - 8%
Which anti-D has the most evidence in treatment of PMS and PMDD?
Fluoxetine
What instrument did the NCS study use?
Composite international diagnostic interview
National co-morbidity survey - done in the US, didn’t use institutions and didn’t include schizophrenia or non-affective psychoses
Outline the 6 types of bipolar disorder as proposed by Klerman?
Bipolar I: Mania (with depression)
Bipolar II: Hypomania (with depression)
Bipolar III: Cyclothymic disorder / personality
Bipolar IV: Hypomania or mania precipitated by antidepressant drugs
Bipolar V: Depressed patients with a family history of bipolar illness
Bipolar VI: Mania without depression (unipolar mania)
What group had the lowest risk of psychosis in the AESOP study?
White british
What is the prevalence of post-natal depression?
25%
Antipsychotic induced dystonias is more common in which groups of people?
Young men
The rate of Clozapine induced sialorrhoea is?
31%
What proportion of patients with BPD have been sexually abused?
55%
Why can oxazepam cause withdrawal symptoms in between doses?
Due to its short half-life 6 - 10 hours
Which antipsychotics are safe for QTc?
Clozapine, Olanzapine, Paliperidone, Risperidone, Amisulpride & Aripiprazole - all low risk on QTc
What percentage of people attend their GP in the week before completed suicide?
1 in 5
What percentage of dementia patients exhibit inappropriate sexual acts
7 - 25%
What is the SAD PERSONS pneumonic for suicide risk factors?
Sex - 1 male
Age - 1 if < 20 or > 44
Depression
Previous attempt
Ethanol abuse
Rational thinking lost
Social support lacking
Organised plan (1 if made and lethal)
No spouse - 1 if divorced, separate, single or widowed
Sickness - 1 if chronic, debilitating and severe
What are the 5 principles of the mental capacity act?
- Assume capacity unless otherwise
2, Individual should not be regarded as unable to make a decision until all practical steps to help him do so have been undertaken without success
- An individual is not treated as unable to make a decision just because that decision is unwise
- Any action or decision made under the act for or on behalf of an individual who lacks capacity must be done so in his best interest
- Regard must be done so that the intervention under the act is the last restrictive way
What percentage of patients seen in the following environments have a personality disorder
- General population
- GP
- Psych OPD
- Prison
- 4-5%
- 10-12%
- 33%
- 40 - 60%
Name the brown and harris vulnerability factors?
Early maternal loss
Lack of confidant
Caring for young children (more than 3 < age 14 years)
Unemployment
Which SSRI can cause vaginal dryness?
Paroxetine
Which personality disorder may hoarding present in?
Anankastic PD
What is bipolar disorder type 3 coded as in ICD?
Bipolar disorder NOS
What is another term for obstructive sleep apnoea?
Pickwickian syndrome
What assessment scale may be appropriate to monitor clinical recovery and measure clinical outcomes?
Health of nations outcome scale
Outline the symptoms of acute porphyria?
Typically get severe pain (abdomen typically but can be thigh/calf) accompanied with nausea/vomiting.
During attacks they can be confused and may act out of character
Attacks can be triggered by alcohol or hormonal changes
Name some features of neurosyphillis
High stepping gate
Dilated pupils
- infection with treponema pallidum
A term used to refer to a stoke patients intense emotional reaction when asked perform an activity they are unable to do?
Catastrophic reaction
Outline features of…
a) Lead poisoning
b) Mercury poisoning
c) Manganese poisoning
d) Thallium poisoning
e) Arsenic poisoning
a) Encephalopathy that can lead to intellectual impairment. Anorexia and colic abdominal pain - can present with psychosis later down the line
b) Lethargy and restlessness. GI irritation causes - bleeding, bloody stools, vomiting and collapse. Depression and mild cognitive impairment including attentional difficulties, anxiety and agitation
c) Headache, irritability, somnolence (manganese madness). Basal ganglia damage can produce Parkinson like features
d) Thallium in rat poison can produce diarrhoea/vomiting, delirium, convulsions, cranial nerve palsies, choreiform movements and coma. Paranoid thinking and depression can occur as well as alopecia
e) Mild impairment of new memory learning and concentration
How does CJD present?
Myoclonus - brief asymmetric jerks in the extremities
How does neuroacanthocytosis present?
Peculiar gait with long strides and quick involuntary knee flexion
GTC seizures and a subcortical dementia. Other neurological features include ataxia, personality changes, cognitive deterioration, axonal neuropathy and seizures
What proportion of self-harm is attributable to individuals > 65 years?
5%
For individuals who self-harm what is their 10-year risk of suicide?
3% (according to Owens 2002)
How many self-harm again after attending A&E? (from Owens 2002)
40%
