ICSM Year 5 Psychiatry Flashcards
1
Q
What is the medical term for the state before falling asleep?
A
Hypnagogic
2
Q
What is the medical term for the state before waking up?
A
Hyponopompic
3
Q
What is an extracampine hallucination?
A
A sense of presence/ movement in the absence of a stimulus
4
Q
What is an elemental hallucination?
A
Simple hallucinations eg. flashes of light/ noise
5
Q
What is the term given to visual hallucinations in individuals who have lost their sight?
A
Charles de Bonnet syndrome
6
Q
What are the 4 types of auditory hallucination?
A
- Thought echo (pt’s thoughts are projected out loud)
- 3rd person voices
- Running commentary
- Command
7
Q
What is formication?
A
The tactile hallucinatory feeling of bugs crawling under your skin
8
Q
What is the name given to the perception of meaningful images from a vague stimulus?
A
Pareidolic illusion
9
Q
What is a delusion?
A
A fixed, false belief, held despite evidence to the contrary that is not explained by the patient’s background
10
Q
What is a reference delusion?
A
Patient believes unsuspicious thing has reference to them, eg. TV programme dialogue refers to them
11
Q
What is Ekbom’s syndrome?
A
The belief that one is infected with parasites
12
Q
What is the difference between hypochondriasis and Munchausen/
factitious disorder?
A
Hypochondriasis is unconscious pretending to have a medical disorder, whereas Munchausen is conscious
13
Q
What is Othello syndrome?
A
False belief partner is being unfaithful
14
Q
What are the names given to a delusionary disorder of excessive sexual desire
(eg VIP is in love with them)?
A
Erotomania/ De Clerembault’s syndrome
15
Q
What is capgras syndrome?
A
Belief that a close acquaintance has been replaced by an imposter
16
Q
What is fregoli syndrome?
A
False belief that different people are in fact same person in multiple disguises
Fregoli was Italian actor - think one person acting as many
17
Q
Recall the 3 types of thought disorder
A
Insertion, withdrawal and broadcasting
18
Q
What is Cotard’s syndrome?
A
Nihilistic delusion in which pt believes they are rotting/ dead - can occur in severe depression
19
Q
What is Knight’s move thinking?
A
Absence of clear links between successive thoughts
20
Q
What is flight of ideas, and what psychiatric disorder is it a feature of?
A
Jumping of thoughts but, unlike Knight’s move, with a CLEAR LINK between ideas. A feature of mania but not of psychosis
21
Q
What is the name given to when a person cannot answer a question without going into massive extra detail?
A
Circumstantiality
22
Q
What is a neologsim?
A
The formation of new words, which may involve the combining of two words
23
Q
When was the MHA made?
A
2007
24
Q
Recall and differentiate between the 4 different non-emergency sections of the MHA under which a patient may be detained
A
Section 2: admission for assessment
Section 3: admission for treatment
Section 5(2) Holding for a patient already on the ward
Sectrion 136: Police order to remove someone who is mentally ill from a public place to a place of safety
25
What is the maximum duration of each of the non-emergency sections of the MHA?
Section 2: 28 days
Section 3: 6 months
Section 5(2): 72 hours
Section 136: 24-36 hours
26
What is the requirement for recommendation for detainment under each of the non-emergency sections on the MHA?
```
Sections 2 and 3 = 2 doctors, with at least one being Section 12 approved
Section 5(2) = 1 doctor
Section 136 = a police officer
```
27
Under what section of the MHA is emergency treatment undertaken, and who may apply for it?
Section 4 - it only needs ONE doctor because it's an emergency and the doctor MUST be S12 approved (a psychiatrist)
28
Who may apply for section 2/3 detainment under the MHA?
AMHP (approved mental health professional) or NR (nearest relative)
29
Who may apply for discharge from a section 2 MHA detention?
NR or Mental Health Review Tribunal (MHRT) within first 14 days of detention
OR
At any time: by the responsible clinician
30
Recall the process for forcibly medicating someone under the MHA
Under Section 3 can be forcibly medicated for 3 months, if then not consenting, need a SOAD assesment (second opinion appointed doctor)
31
What qualification is required for someone to detain a patient under Section 4 of the MHA?
Must be a psychiatrist
32
What does section 5(4) of the MHA allow?
Detention of an inpatient by a nurse
33
What is the maximum duration of detention under section 5(4) of the MHA?
6 hours (detention by nurse)
34
What does section 17 of the MHA allow?
Allows leave from a current section, but is not permanent discharge
35
What does section 35 of the MHA permit?
Assesment of a patient accused of committing a crime
36
How long does assesment last under section 35?
28 days
37
What are the appeal requirements to section 35 of the MHA?
You can't appeal
38
What does section 37 of the MHA permit?
Treatment of a convicted criminal - otherwise like section 3
39
What are the appeal requirements to section 37 of the MHA?
Within 21 days to court, after 6 months to the MHRT (mental health review tribunal)
40
What section of the MHA is applied for by the Crown Court?
Section 41 - a restriction order
41
Under which section of the MHA can a serving prisoner be transferred to hospital?
Section 47 - when restriction is added = section 49
42
What is a community treatment order?
Discharge from a previous section providing certain conditions are met - requires renewal every 6 months
43
Describe the role of the Approved Mental Health Professional
95% are social workers, and are responsible for coordinating the assessment and admission of a patient to hospital if needed
44
Describe the role of the Independent Mental Health Advocate
Advocate trained to help the patient find out their rights under the MHA and provide support - you can't have one under sections 4, 5, 135 or 136
45
What does DoLS stand for?
Deprivation of Liberty Safeguards (within MCA 2005) - which can be within a carehome or hospital
46
What is the mechanism of action of most antipsychotic drugs vs clozapine?
Dopamine receptor antagonists - most block D2 but Clozapine blocks D1 and D4
47
Recall some common side effects of anti-psychotics
Extrapyramidal - dystonia/ akathisia/ parkinsonisms/ tardive dyskinesias (more common in typicals)
Hyperprolactinaemia (galacorrhoea, amenorrhoea, gynaecomastia)
Weight gain
48
Why do atypical antipsychotic drugs have fewer side effects than typicals?
More selective (just antagonise D2 and 5-HT2 receptors)
49
What class of drug is the first line treatment in schizophrenia?
Atypical antipsychotic
50
What class of drug is the first line treatment in relapsed schizophrenia?
Typical antipsychotic
51
In the elderly, what extra risk do antipsychotic drugs carry?
Increased risk of stroke and VTE
52
Describe how the dosage of clozapine is controlled
Start low and titrate up slowly, if >48 hours missed medication, need to start again
53
Recall one caution of using clozapine
If patient stops smoking suddenly, the clozapine levels will suddenly go up
54
Recall 2 examples of typical antipsychotics
Haloperidol, chlorpromazine
55
Recall 4 examples of atypical antipsychotics
Clozapine, risperidone, apiprazole, olanzapine, quetiapine
56
Recall one significant side effect to remember of clozapine
Agranulocytosis (1%)
57
Recall one drug interaction of clozapine
Lithium
58
What is neuroleptic malignant syndrome?
A major side effect of antipsychotics characterised by fever, altered mental status, muscle rigidity, and autonomic dysfunction
59
What is akathisia?
An unpleasant subjective feeling of restlessness
60
What is tardive dyskinesia?
Rhythmic involuntary movements of the mouth, face, limbs and trunk
61
Describe the monitoring process for patients who take antipsychotic medications
Basic obs + bloods (more frequent for clozapine) + assessment of movement disorders, nutritional status and physical activity + ECG if CVD risk factors present
62
When should an FBC be done in a patient taking clozapine?
At frequent intervals for monitoring + every time there's an infection as need to check there's no agranulocytosis
63
Recall the symptoms of suddenly stopping antidepressant medication
```
FIRM STOP
Flu-like symptoms
Insomnia
Restlesness
Mood swings
```
Sweating
Tummy problems
Off-balance (ataxia)
Paraesthesia
64
Recall 4 examples of SSRIs
For Sadness, Panic, Compulsion:
| Fluoxetine, sertraline, paroxetine, Citalopram
65
For approx how long do SSRIs make someone feel worse before they feel better?
1-2 weeks
66
Recall one important risk of SSRIs
May increase suicidal thoughts/ self-harm risk
Depression can stop people performing ADLs due to extreme lethargy/ apathy - when antidepressant begins to work and enable people to do things again, they are also more able to act on thoughts of self-harm
67
Recall one important interaction of SSRIs
Triptans - interaction can cause serotonin syndrome - so ask about migraines
68
Recall one important side effect of citalopram
QT prolongation
69
Recall one important side effect of sertraline
Can cause arrhythmias and QT prolongation - but still the antidepressant of choice following an MI (this was asked in a PPQ so nb)
70
Recall the main side effects of all SSRIs
```
The 5 'S's:
Suicidal idealisation
Stomach (weight gain, DNV)
Sexual dysfunction
Sleep (insomnia)
Serotonin syndrome
```
71
When prescribing an SSRI for anxiety, how long should you advise the patient it may take to work?
Anxiety may initially worsen, will need 4-6 weeks to work
72
How long should SSRI medications be continued for?
6 months after remission of first episode, 2 years after remission if it's a recurrence - gradually stop over 4 weeks
73
Recall 3 drugs that should be avoided in suicide risk, and 2 that are particualrly useful when there is a suicide risk
Avoid: TCAs, MAOIs, Venlafaxine - lethal in OD
Use: SSRIs (despite INITIAL suicide risk) or mirtazapine
74
How should different SSRI medications be switched?
Reduce dose over 2 weeks before starting another SSRI
If fluoxetine, wait 4-7 days after before starting new SSRI, due to long half life
75
What does SNRI stand for?
Serotonin-noradrenaline reuptake inhibitor
76
What is the main side effect of SNRIs?
Headache
77
Recall 2 examples of SNRIs
Venlaxafine, duloxetine
78
Describe the side effects of SNRIs
Same '5S' as SSRIs but also constipation, HTN + raised cholesterol
79
What is the mechanism of action of TCAs?
Block serotonin and NA reuptake
80
What can TCAs be used for at low vs high doses?
Low dose: blocks H1 and 5HT and aids sleep
Higher doses: blocks all receptors and is used in depression
81
Why are TCAs not given if there is risk of suicide?
Can be fatal in OD
82
What is one key contraindication for TCAs?
If patient is also taking a monoamine oxidase inhibitor
83
Recall the side effects of TCAs
TCA:
Thrombocytopaenia
Cardiac (QT prolongation, ST elevation, heart block, arrhythmias)
Anticholinergic (urinary retention, dry mouth, blurry vision, constipation)
Also:
Weight gain and sedation from histaminergic receptor blockade
Postural hypotension from alpha-adrenergic receptor blockade
84
What are the anticholinergic side effects that are possible with all types of antidepressant?
"Can't see, can't pee, can't spit, can't shit"
85
Give 2 examples of TCAs
Amitriptyline, clomipramine
86
What type of antidepressant is mirtazapine?
noradrenergic and specific serotonin antidepressant (NaSsA)
87
What is the most common side effect of mirtazapine?
Weight gain
88
When is mirtazapine indicated?
Triad of depression + insomnia + loss of appetite
89
Give 2 examples of MAOI antidepressants
Phenelzine, selegiline
90
What does MAOI stand for?
MonoAmine Oxidase Inhibitor
91
What is the main risk of MAOI use?
Hypertensive cheese reaction
92
What type of antidepressant is moclobemide?
Reversible Inhibitor of Monoamine oxidase A (RIMA)
93
What is the max length of prescription for a BDZ drug?
2-4 weeks
94
What is the mechanism of action of BDZs and BARBs?
Enhance GABA transmission at GABA-A receptor
95
How does the mechanism of action of BDZs and BARBs differ?
BDZ increases duration of receptor opening, BARB increases frequency of opening
96
Why are barbiturates more dangerous than BDZs?
Less selective so more excitatory transmission
97
Give 3 examples of long-acting benzodiazepene medications, and what these are useful for
Diazepam, lorazepam, chlordiazepoxide
Useful as an anxiolytic, in delirium tremens/ acute alcohol withdrawal
98
What is the difference between a sedative and a hypnotic drug?
Sedative reduces physical + mental activity without producing a loss of consciousness, whereas hypnotic will induce sleep
99
Give 2 examples of short-acting BDZs and recall their main clinical use
Teazepam, oxazepam - used as sedatives
100
What is a Z drug used to treat?
Treats insomnia (similar to a BDZ)
101
Give an example of a Z drug
Zopiclone
102
When should Z drugs be used?
Only when insomnia is severe and disabling
103
What is a key side effect of zopiclone?
Increased risk of falls
104
Describe the withdrawal process from zopiclone
1/8th the daily dose every 2 weeks: reduce by 5mg every 2 weeks until 20mg/day, then reduce by 2mg every 2 weeks until 10mg/day, then reduce by 1mg every 2 weeks until 5mg/day, then reduce by 0.5mg every 2 weeks until completely stopped
105
What is the antidote to zopiclone, and its mechanism of action?
Flumenazil (BDZ antagonist)
106
Why should zopiclone not be used in pregnancy?
Can cause a cleft lip
107
What are stimulants used to treat?
ADHD and narcolepsy
108
Give 2 examples of stimulant drugs used to treat ADHD
Methylphenidate (Ritalin)
| Dexaphetamine
109
What is the mechanism of action of stimulant drugs used in ADHD?
Potentiate the effect of monoamine neurotransmitters (DA, NA, 5HT)
110
Recall some side effects of stimulant drug use
Cardiac pathology, drug-induced psychosis, appetite suppression, "risky" behaviour, insomnia, impulsivity
111
What are mood stabilising drugs used to treat?
BPAD, schizoaffective disorder
112
What are the 4 main mood stabilising drugs?
Lithium (1st line), valporate (2nd line), carbamazapine, lamotrigine
113
Recall 4 key side effects of lithium
Mild tremor, hypothyroidism, eyebrow hair loss, nephrogenic DI
114
How does a lithium OD present?
```
Tremor
Ataxia
GI disturbance/ urinary symptoms
Seizures
AKI
```
115
What regular monitoring should be done in lithium prescription?
Every 3 months: lithium levels, every 6 months: UandEs and TFTs
116
Why should lithium not be used in pregnancy?
Causes Ebstein's abnormality (heart defect)
117
Recall 2 key side effects of valporate
Hair loss + weight gain
118
What is the main risk of using valporate in pregnancy?
Spina bifida - do not prescribe to a woman of child-bearing age unless a pregnancy prevention programme is in place
119
What is the main risk of using carbamazipine in pregnancy?
Spina bifida
120
What is the key side effect of lamotrigene use?
Severe skin rash - SJS
121
What is the most likely drug to cause the neuroleptic malignant syndrome?
Haloperidol
122
Recall the symptoms of the NMS
Gradual onset triad of mental status change (catatonia), muscular rigidity + autonomic instability (hyperthermia + labile BP)
"MMA" fighters are muscular, mental and (autonomically) unstable
123
In what time frame does the NMS develop?
4-11 days after starting any antipsychotic medication
124
What investigations should be done to identify NMS?
FBC (to show leucocytosis), UandEs (show high CK and AKI)
125
How should the NMS be managed?
1. ABC
2. AandE/ITU admission
3. Stop antipsychotics
4. Supportive (fluids, dialysis etc to deal with AKI)
5. Dantrolene, bromocriptine
126
Recall the symptoms of the serotonin syndrome
Abrupt onset triad of mental state change, neuromuscular changes and autonomic instability (so very similar to NMS but abrupt onset rather than gradual)
127
What symptom is likely to present in the serotonin syndrome but not the NMS?
Diarrhoea and Vomiting
128
How does management differ in the serotonin syndrome compared to the NMS?
All the same except the drug used is a BDZ (clonazepam) rather than dantrolene and bromocriptine
129
How does ECT work?
Induces a generalised tonic-clonic seizure under general anaesthetic
130
What are the indications for ECT?
ECT:
Euphoric (manic episodes)
Catatonia (not moving in an unusual position)
Tearful (severe depression that is life-threatening)
131
What is an absolute contraindication for ECT?
Raised intracranial pressure
132
What are the short term side effects of ECT?
Headaches and nausea, muscle aches, cardiac arrhythmia, retrograde amnesia (loss of memories before the ECT)
133
What is the main target of CBT?
So-called 'Negative Automatic Thoughts'
134
What is Beck's negative cognitive triad
Self-perpetuating triad of:
- Negative self-view
- Negative future view
- Negative world view
135
Describe the negative cycle that CBT aims to tackle
Thoughts (eg "She didn't smile at me when she walked past") --> emotions ("I'm such a nobody, no one acknowledges me" --> behaviours ("I'm going to avoid everyone and not waste their time")
136
Recall the name of 2 CBT methods used to tackle negative thought patterns
Longitudinal format/ hot-cross bun methods
137
Describe the longitudinal format of CBT
1. Get a detailed history from early life to present - identify early experiences, critical incidents etc
2. How do these early experiences affect core beliefs? (Beck's triad)
3. Identify NATs - eg mental filters/ predictions/ mountains and molehills
138
What is the theoretical basis of psychodynamic psychotherapy?
Problems are shaped by childhood experiences --> causes conflict between conscious and unconscious mind, therapy reveals unconscious mind
139
What is the difference between psychoanalytics and psychodynamics?
```
Psychoanalytics = internal conflicts
Psychodynamics = interpersonal conflicts
```
140
How does the aim of psychodynamic psychotherapy differ from CBT primarily?
Aims to change personality and emotional development, rather than aiming to understand thoughts and see how that impacts the individual
141
Recall 4 protective factors against suicide
Married, lithium medication, faith, no substance abuse
142
What is the reversing agent for overdose on a BDZ?
Flumenazil
143
What is the reversing agent for overdose on a Z drug?
Flumenazil
144
What is the reversing agent for overdose on an opiate?
Naloxone
145
What is the reversing agent for overdose on paracetamol?
N-acetylcysteine
146
What is delirium?
Disturbance of attention/ awareness that develops over a short period of time that is a change from baseline - that can't be better explained by another condition
147
What are the most important differentials to consider in delirium?
Infection, medication and constipation but there are SO MANY causes, look for many and don't be satisfied with one
148
How is delirium diagnosed?
Confusion Assesment Method
149
How is delirium managed?
Modify risk factors, exclude diagnosed dementia, treat the causes
150
What is the medical management of delirium?
PO antipsychotics, AVOID anticholinergics
151
What is the prognosis for delirium?
37% die within 6 months, only 25% have a clinically important recovery in ADLs
152
What drug can be used IM to rapidly tranquilise if the individual refuses PO medications?
IM lorazepam
153
Recall 3 things that are important to consider before the administration of rapid tranquilisation
1. Is there an advance decision in place?
2. What is the therapeutic goal (ie. desired level of sedation)?
3. What medicines have they had in the past 24 hours, and how did they respond?
154
How should the INITIAL method of rapid tranquilisation differ between an unknown/ neuroleptic naïve patient, and a patient with a confirmed history of antipsychotic use?
PO medication (not IM)
Unknown/naïve pt: lorazepam
Known/confirmed antipsychotic use: lorazepam/ olanzapine/ haloperidol AND promethazine (acronym = Lots Of Hallucinations and Panic)
155
How long should be left to assess a patient's response to oral tranquilisation?
1 hour at least
156
What is the convention for IM tranquilisation in an unknown/ neuroleptic naïve patient?
1. IM Lorazepam - wait 30 mins for a response
If response only partial - repeat IM lorazepam dose
If no response: WAIT until >1hr since lorazepam, then give IM olanzapine OR IM haloperidol with promethazine
(note - check there is no cardiac disease with ECG)
Acronym for orders of anti-psychotics = Lots Of Hallucinations AND Panic (Lorzaepam, Olanzapine, Haloperidol AND promethazine)
157
What is the most important factor to guide use of IM medication for rapid tranq in a known patient/ patient with a confirmed history of antipsychotic use?
Presence/ absence of cardiac disease
158
What is the convention for administering IM tranquilisation in a known patient with NO cardiac disease?
Start with haloperidol with promethazine (think - makes sense that last thing on rapid tranq ladder (L-->O --> P+H) is for patients who are known and definitely do not have cardiac disease) -
Wait 30 mins for response and repeat if response only partial
If no response: lorazepam (if not already used) or olanzapine
159
What is the convention for administering IM tranquilisation in a known patient WITH cardiac disease?
1. Lorazepam - wait 30 mins for response OR olanzapine (repeat if partial response)
2. If no response: wait 1 hour, then give lorazepam/ olanzapine
160
Recall the dosing for oral rapid tranquilisation medications
Lorazepam: 1-2mg (max in 24 hours = 4mg)
Olanzapine: 5-10mg (max in 24 hours = 20mg)
Haloperidol: 5-10mg (max in 24 hours = 20mg)
Promethazine: 25-50mg (max in 24 hours = 100mg)
161
Recall the dosing for IM rapid tranquilisation medications
Lorazepam: 1-2mg (max in 24 hours = 4mg)
Olanzapine: 5-10mg (max in 24 hours = 20mg)
Haloperidol: 2.5-5mg (max in 24 hours = 12mg)
Promethazine: 25-50mg (max in 24 hours = 100mg)
162
Describe how rapid tranquilisation should be monitored
Ensure baseline is taken
For oral PRN: monitor hourly for minimum one hour on NEWS form
For IM monitor every 15 mins for minimum 1 hour on rapid tranquilisation monitoring form
163
What are the 2 core symptoms of depression?
Low mood + anhedonia
164
What are the adjunct symtpoms of depression?
```
Fatigue
Insomnia
Concentration problems
Appetite change
Suicidal thoughts/ acts
Agitation/ slowing of movements
Guilt
```
165
Recall 3 medications that may cause depression
Steroids, COCP, propranalol
166
What is dysthymia?
Subthreshold depression (2-5 symptoms) of depression for at least 2 years
167
What is atypical depression?
Just somatic symtpoms (weight gain, hypersomnia)
168
What can improve the symptoms of anxiety-induced insomnia?
Mood is increased by increased sleep and eating
169
What is a depressive stupor?
Such extreme psychomotor retardation that the individual grinds to a halt
170
Recall the roles of the different monoamines, which are reduced in depression
Noradrenaline (mood, energy)
5-HT/serotonin (sleep, appetite, memory, mood)
Dopamine (psychomotor activity, reward)
171
How would you go about investigating for depression?
Full history and collateral history, physical exam and MSE, bloods to check for anaemia, hypothyroidism and diabetes, and a rating scale (Eg PHQ9, CDI (children), EPDS (pregnancy)
172
Describe the MSE
Appearance
Behaviour
Speech (rate, tone, volume)
Emotion (mood subjective and objective, affect)
Thought (formal thought disorder? Content? (delusions)
Perception (illusion and hallucination)
Cognition (orientation to time/ place/ person), AMTS/MOCA score
Insight (into both diagnosis and treatment)
173
How is depression treated in children and young people?
If mild, watchful waiting, self-help and lifestyle advice
If moderate-severe:
- 5-11 y/os = family therapy, IPT/ individual CBT, referral made through CAMHS
- 12-18 y/os = psychological intervention, probably individual CBT, if really bad + fluoxetine
Must try and avoid medication if at all possible
Intensive psychological therapy thorugh CAMHS if completely unresponsive to treatment
174
How is depression treated in adults?
Check suicide risk
Step one: if initial suspected depression / subthreshold symptoms --> watchful waiting, with follow up in 2 weeks, education about sleep/ mind.co.uk etc
Step two: if persistent subthreshold/ mild symptoms: group/ computerised CBT/ guided self-help - only give medication if subthreshold symptoms last longer than 2 years
Step three: moderate symtoms/ persistent subthreshold refractory to step 2: individual CBT/IAPT + medications with regular review every 2 weeks for 3 months (or every week if suicidal )
Step four: severe depression/ risk to life/ neglect: high-intensity psychsocial interventions, section if necessary, medications, ECT if necessary
175
What is the first line antidepressant medication?
SSRIs (sertraline, citalopram, fluoxetine, paroxetine)
176
When should a second line antidepressant be tried?
After trying 2 different SSRIs
177
What is the second line antidepressant medication?
SNRIs (venlaxafine, duloxetine)
178
Recall the stepped increase of dose of venlaxafine
37.5mg BD --> 75mg BD --> 75mg morning, 150mg evening
179
What is the indication for 3rd line antidepressant treatment?
If they are resistant to treatment, you can't augment treatment with further medication
180
What are the 3rd line treatment options for depression medication?
Antipsychotic (eg quetiapine), lithium, or other antidepressant eg mirtazapine
181
What is the ideal blood level of lithium?
0.6-1.0 (toxicity at >2.0)
182
In which scenario is mirtazapine most useful?
When symptoms of insomnia and appetite reduction are evident and debilitating
183
Describe the side effect profile of sertraline
Smallest side-effect profile, so a good one to give to people with comorbid IHD
184
What is the best antidepressant to give to children?
Fluoxetine
185
What is the most common use of paroxetine?
For major depressive episodes
186
When should paroxetine not be used and why?
Pregnancy: in 1st trimester may cause congenital heart defects, in 3rd trimester may cause persistent pulmonary HTN
187
How can you differentiate between psychotic depression and schizophrenia in the history?
"He wants to kill me", "Why is that?", "the world is better off without me" = depression, "I have no idea, but I got the message " = schizophrenia
188
How is BPAD defined in the ICD-10?
>/= 2 episodes, 1 must be manic, mania lasts around 4 months, depression lasts around 6 months, there is complete recovery between 2 episodes
189
How can a manic episode be identified?
It's more associated with irritability than elevated mood - they may have grandiose delusions, flight of ideas, over-optism OR suicidal ideas
190
How is mania diagnosed?
Need at least 3 characteristcs of mania on the MSE, lasting at least 7 days and causing an impaired occupational/ social functioning +/- psychosis
191
What is hypomania?
>3 characteristics of mania lasting at least 4 days, no impairment of functioning, no delusions/ psychosis
192
What is the difference between type 1 and type 2 BPAD?
Type 1 has proper manic episodes, type 2 has recurrent depressive episodes with less prominent hypomanic episodes
193
What is rapid cycling BPAD?
More than 4 episodes per year
194
What is the best treatment for rapid cycling BPAD?
Sodium valporate - they respond well
195
How much is BPAD risk increased by a 1st degree relative having BPAD?
7 fold
196
What is the rating scale used to investigate BPAD?
Young mania rating scale
197
Why can BPAD be hard to pick up on?
Most BPAD patients present in their depressive episodes, so you always need to ask about mania symptoms
198
Recall some differentials for BPAD?
Organic: drugs, dementia, frontal lobe disease, delirium, cerebral HIV
Schizophrenia
Cyclothymia (persistent mild mood instability - never severe enough to cause BPAD/ depression)
Puerperal disorders
199
How should the urgency of referral be judged in suspected BPAD?
If there's hypomania just do a routine referral to CMHT, if it's full-on mania do an urgent referral to CMHT or admit
200
How should acute mania be treated?
Gradually taper off and stop medications (eg SSRIs), monitor fluid and food intake, may need to sedate
If not on treatment: aim to stabilise them before starting lithium
If already on treatment, check lithium levels - it might be atypical
If on treatment, also optomise current medications and stop antidepressants
201
How should mania be managed in the longterm?
First line is lithium alone - which needs regular monitoring and may take up to 5 weeks to titre correctly
Second line is adding valporate (which doesn't need monitoring but has naff side effects like hair loss, weight gain and nausea)
If lithium isn't tolerated try olanzapine/ valporate alone
202
How do you manage BPAD if they have comorbid depression?
You can't use antidepressants alone as they may cause mania!
Try first: fluoxetine and olanzapine
Seond try quetiapine alone
203
What is the use of psychological therapies in BPAD?
May improve compliance with medication long term
204
What is the prognosis for BPAD?
15% willl commit suicide, but lithium reduces this to same level as general population
205
How does the ICD-10 define schizophrenia?
A. More than 1 of Shneider's 1st rank symptoms for >=1 month duration -
These are:
- Formal thought disorder (echo, insertion, withdrawal, broadcasting)
- Delusions of passivity/ control
- Other bizzare delusion
- Running commentary hallucination
206
Describe the progression of schizophrenia
1. Prodrome/ at-risk mental state: the negative symptoms are dominant, there is social withdrawal and loss of interest in work/ relationships
2. Acute phase (positive symptoms dominant) - eg delusions, halllucinations and thought interference
3. Chronic
207
What is wavy flexibility?
They will retain any shape you put them into!
208
What is the most common subtype of schizophrenia?
Paranoid schizophrenia
209
What are the different subtypes of schizophrenia, and how are they characterised?
Paranoid - prominent delusions and hallucinations
Hebephrenic/ disorganised - mainly focused on speech/ thought, disorganised mood and speech, neologisms and knight's move thinking, inappropriate affect (eg laugh at something sad)
Catatonia - psychomotor disturbance - stupor, wavy flexibility, automatic obedience, forced grasping
Simple - negative symptoms only eg apathy and social withdrawal
210
How does cannabis use increase risk of schizophrenia?
Val allele encoding COMT insead of Met allele in non-smokers
211
What rating scale is used to investigate schizophrenia?
Brief psychiatric rating scale
212
What type of prescription drug use may cause symptoms of schizophrenia?
Steroids
213
What is schizoaffective disorder?
Schizophrenic and affective symptoms develop together and are balanced
214
What is schizotypal disorder?
Eccentricity with abnormal thoughts
215
By what teams should schizophrenia be managed in an urgent emergency?
Crisis Resolution Team and Home Treatment Team
216
By which team should schizophrenia be managed when it is not urgent?
Early Intervention in Psychosis (EIP) team
217
Recall the stepwise biological treatment of schizophrenia
1st line (6 wks): atypical antipsychotic - apiprazole/ quetiapine are more gentle, olanzapine/ risperidone are stronger and have more side effects
- Can augment these treatments with BDZ/ mood-stabiliser (lithium/ valporate)
2nd line (6 weeks): typical antipsychotic
3rd line (if treatment resistant): clozapine
218
Recall the psychological treatment of schizophrenia
1st line is CBT, which should be offered to all patients regardless of severity of schizophrenia - emphasis is on testing reality. Note: NOT proven to be effective for schizophrenia without concomitant pharmacological intervention.
2nd line is family therapy, especially if the patient is young - it helps to control the highly expressed emotions of schizophrenia and helps the family to cope
219
Recall the community monitoring that is important when treating someone for schizophrenia
1. Baseline measurements - their basic obs, bloods, a screen for movement disorders, assesment of nutritional status and an ECG (as CV risk is bad in quite a few of the meds)
2. There is a high CVD risk in patients on schizophrenia medications so monitor
220
What kind of things influence schizophrenia prognosis?
Good prognostic indicators: sudden onset, late in ilfe, due to a stressful event, with no FHx and a higher IQ
Bad prognostic indicators: gradual onset, early in life, with a lack of precipitating factor, a pos FHx and a lower IQ
221
What are the different subtypes of schizoaffective disorder, and how do they differ?
Manic and depressive type - the manic type combines schizophrenia and mania, the depressive type combines schizophrenia and depression - in both the non-schizophrenic symptoms are more prevalent
222
How long do psychotic episodes need to last for a diagnosis of schizoaffective disorder?
>= 2 weeks
223
What are the diagnostic requirements for schizoaffective disorder?
2 episodes of psychosis are required:
1 must last >2 weeks without any symptoms of mood disorder
1 must demonstrate an obvious overlap of mood and psychotic symptoms
224
How should schizoaffective disorder be treated?
As per schizophrenia, and if the affective component is not being controlled add a mood stabiliser
225
How quickly must psychosis resolve in order for it to be classified as an acute episode?
Within 3 months - and aim is to keep symptoms to <3m duration as psychosis is toxic to the brain
226
How should acute psychosis be managed?
Biological: Antipsychotics short-term/ BDZ (eg high dose olanzapine) + antidepressants/ mood stabilisers
Psychosocial: try to deal with specific social issues too, and add reality-oriented psychotherapy
227
What is delusional disorder, according to the ICD-10?
Persistent/ life-long delusions with no/few hallucinations: cannot inclue schizophrenic symptoms/ evidence of organic or brain disease/ clear auditory hallucinations
228
How does onset affect prognosis in psychosis?
Rapid onset is associated with a better prognosis
229
How should delusional disorder be managed?
There's poor evidence for biologicals in this disorder - may use a BDZ for anxiety
Psychosocial - lots of psychoeducation, and social skills training
230
Recall the important elements of the history in anxiety disorders
```
Anxious people want to be SEDATED
S - symptoms of anxiety
E - episodic/ continuous?
D - drink/ drugs?
A - avoidance and escape
T - timing and triggers
E - effect on life
D - depression
```
231
If the history reveals episodic anxiety, which 3 differentials should be considered?
Phobia, OCD, PTSD
232
What type of psychological therapy is best for phobias?
Exposure therapy
233
What type fo psychological therapy is best for OCD?
CBT
234
Which anxiety disorders can be treated with medication, and which medication is best?
All of them - with SSRIs - most often sertraline
235
What is the prognosis for anxiety generally?
Rule of 1/3s - 1/3 recover fully, 1/3 improve partially, 1/3 fare poorly
236
How is GAD defined in the DSM-V?
At least 6 months of excessive, difficult to control worry and everyday issues that causes distress/ impairment
237
Recall the possible symptoms of GAD
```
Restlessness
Irritability
Fatiguability
Muscle tension
Sleep disturbance
Poor concentration
```
238
How many symptoms need to be present most of the time for a GAD diagnosis?
3
239
What questionnaire is useful in diagnosis of GAD?
GAD-7
| Beck's anxiety inventory/ HADS can also be used
240
Recall the stepwise management for GAD
1. Written information + exercise
2. Low intensity psychological intervention - self-help or a psychoeducational group
3. High intensity psychological interventions or medications (step-wise)
- CBT/ applied relaxation
- Step 1 = SSRI/ paroxetine (8 weeks)
- Step 2 = different SSRI (like depression)
- Step 3 = SNRI (venlaxafine) + weekly follow up
- Step 4 = pregabalin (antiepileptic)
- Step 5 = quetiapine (atypical antipsychotic)
Use propranolol as an adjunct for the physical symptoms
241
Which treatments should not be used in phobias?
1. BDZs (high risk of dependence)
| 2. Antidepressants - specific phobias don't respond well
242
What is agarophobia?
Fear of leaving home/ entering shops/ crowds/ public places etc
243
Into which 2 classifications is agarophobia classified?
As either with or without a panic disorder
244
How is agarophobia managed?
1. Education, reassurance and self-help
2. Exposure Response Prevention
3. CBT
245
What is social phobia?
The fear of scrutiny of other people leading to avoidance of social situations
246
How can social phobia and agarophobia be differentiated?
In social phobia they will tolerate anonymous crowds but smaller groups will spike anxiety
247
How can specific phobias managed?
Education/ self-help/ Exposure Response Prevention
| BDZs can be given short term
248
What is panic disorder?
Recurrent attacks of severe anxiety that are not restricted to any particular circumstances and are therefore unpredictable
249
What is the maximum duration of a panic attack?
30 mins
250
How is panic disorder managed?
Pretty much same as anxiety with education, self-help, and low-intensity psychological interventions
High intensity treatment:
1st line = CBT + SSRI (citalopram)
If not working after 12 weeks --> change to TCA (imipramine) or add BDZ plus psychodynamic
251
What is OCD?
Disorder that may have recurrent obsessional thoughts or compulsive acts
252
How long do OCD behaviours need to persist for OCD to be diagnosed?
>/= 2 consecutive weeks - must be a source of stress that interferes with ADLs
253
Describe how obsessions are defined
```
SUTURE
Must be:
- Self-recognised as a product of own mind
- Unpleasantly repetitive
- Themed
- Unpleasurable to think about
- Resisted unsuccessfully at least once
- Egodystonic
```
254
Describe how compulsions are defined
Repetitive mental operations or physical acts, in response to own obsessions/ irrationally-defined rules, performed to reduce anxiety through an irrational belief that it will prevent a dreaded event
255
Describe the gender balance of OCD prevalence?
Only anxiety disorder to affect men more than women
256
Which part of the brain can be implicated in OCD?
Basal ganglia
257
What is the rating scale that should be used for OCD?
Yale-Brown OCD scale
258
Recall some examples of good questions to ask in an OCD history
Do you wash or clean a lot?
Do you check the time a lot?
Is there any thought that keeps bothering you that you would like to get rid of
Do your daily activities take a long time to finish
Are you concerned about putting things in a special order or are you very upset by mess?
Do these problems trouble you?
259
How should OCD with mild functional impairment be managed?
CBT with Exposure Response Prevention
260
How should OCD with moderate functional impairment be managed?
Intensive CBT with ERP or SSRI
261
Recall the start doses of fluoxetine for:
1. Depression
2. Anxiety
3. OCD
4. Bulimia nervosa
Depression, OCD: 20mg
Anxiety: 40mg
Bulimia nervosa: 60mg/ 80mg
262
Recall the 4 phases of cognitive therapy for OCD
1. Relabel (tell self hands are not dirty)
2. Reattribute (Tell self it is OCD making them feel that way)
3. Refocus (divert attention)
4. Revalue (do not give importance to OCD thoughts)
263
Define Acute Stress Disorder
A transient disorder that develops in an indivisual without any other apparent mental disorder, in response to exceptional physical and mental stress that usually subsides within hours or days
264
What are the key features of adjustment disorder?
Initial daze, constriction of conscious field, narrowing of attention, inability to comprehend stimuli, disorientation
265
How should adjustment disorder be managed?
Support and reasurance, may give BDZs for short-term distress
266
What may increase the risk of progression to PTSD from adjustment disorder?
Formal, immediate, psychological 'debriefing'
267
How long can adjustment disorder last?
No longer than 6 months
268
Describe the presentation of adjustment disorder
Symptoms of anxiety and depression, without biological symptoms of depression
269
What would make a grief reaction abnormal/ prolonged?
Delayed onset, increasing intensity of symptoms, suicidal idealisation, hallucinatory experiences
270
For how long do symptoms need to persist in order to make a diagnosis of PTSD?
1 month
271
What are the key signs and symptoms of PTSD?
1. Re-experiencing
2. Avoidance of triggers
3. Hyperarousal
272
Which questionnaire should be used in suspected PTSD?
Trauma screening questionnaire
273
How should PTSD be managed?
If symptoms <4 weeks --> watchful waiting + treatment of comorbidities (eg depression)
CBT with 'trauma focus' has best evidence:
- combo of exposure therapy and trauma-focused theray
Or eye Movement Desensitisation and Reprocessing (EMDR)
274
What mnemonic can be used for investigating substance misuse in the history?
```
TRAP:
T = type
R = route
A = amount
P = pattern
```
275
Recall the features of dependency
```
Tolerance
Craving
Withdrawal
Difficulty controlling
Continuing despite negative consequences
Primacy (neglecting other interests)
(reinstatemnt)
(narrowing of repetoire)
```
276
What is the recommended maximum alcohol intake per week?
<14 U (both men and women)
277
How many units EtOH per week are associated with hazardous and harmful drinking?
```
Hazardous = 15-35 units per week
Harmful = > 35 units/ week
```
278
What type of hallucinations may occur in delirium tremens?
Liliputian (seeing little people)
279
What type of seizure might present in alcohol withdrawl syndrome?
Grand-mal
280
What is a useful initial questionnaire for alcohol dependence investigation, and what are the questions?
CAGE
Have you ever tried to Cut down?
Have you ever been Annoyed by people suggesting that you have a problem with your drinking?
Have you ever felt Guilty about drinking?
Have you ever needed a drink to get you going in the morning (Eye-opener)?
281
What are some useful rating scales of alcohol-dependence?
1st line = AUDIT (alcohol use disorders identification test) - 0-7 = low risk
2nd line = SADQ (severity and dependence questionnaire)
282
What alcohol screening tool is used in AandE?
FAST (fast alcohol screening test)
283
What is the triad of symptoms in Wernicke's encephalopathy?
Ataxia, opthalmoplegia, confusion
284
How many units a day does someone need to drink in order to be admitted as an inpatient for withdrawal?
>30 U per day
285
What are the 1st line chronic treatments for alcohol withdrawal?
Acamprosate/ naltrexone
286
What drug should be administered in the case of an alcohol withdrawl seizure?
IV lorazepam
287
What drugs should be administered in delirium tremens?
Oral lorazepam and IV thiamine/ pabrinex
288
What is the mechanism of action of acamprosate?
Enhances GABA transmission to remove craving for alcohol
289
What psychological therapy is appropriate in alcohol detox?
Motivational interviewing
290
What structure is damaged by B12 deficiency?
Mammillary damage
291
What are the symptoms of Wernicke's encephalopathy?
Ataxia, opthalmoplegia, acute confusion (TRIAD)
292
What are the symptoms of Korsakoff's psychosis?
Anterograde amnesia, confabulation, peripheral neuropathy, cerebellar degenration
293
From what plant are opiates derived?
Papaver somniferum
294
What is the most serious infection that you can get from injecting heroin?
Hepatitis C
295
Recall 4 local complications of heroin injection
Abscess, cellulitis, DVT, emboli (AbCDE) + pseudoaneurysm
296
Recall 4 systemic complications of heroin injection?
Septicaemia, infective endocarditis, blood-borne infections, risk of OD
297
Recall the symptoms of heroin intoxication
Euphoria and 'warmth'
OD: pinpoint pupils and low RR
Low-dose side effects: constipation, anorexia, decreased libido
298
How should opiate OD be treated?
Naxolone
299
What are the symptoms of opiate withdrawal?
Craving, insomnia, agitation, flu-like symptoms, the 'runs' (D+V, lacrimation, rhinorrhoea), goose flesh, mydriasis
300
How long after injection of heroin do withdrawal symptoms begin?
6 hours after injection
301
How long do opiate withdrawal symptoms last?
5-7 days
302
How long do opiates stay in the urine?
2 days
303
How should opiate use be managed?
1. Appoint a key worker and develop a care plan
2. Harm reduction - complete abstinence is unlikely so be pragmatic - needle exchange and vaccinations
3. Health education - 'SMART' recovery
304
What are the two stages of Opiate Substitution Therapy?
Stabilisation and detoxification
305
How long does Opiate Substitution Therapy last as an outpatient?
12 weeks minimum
306
What are the first line treatments for Opiate Substitution Therapy?
Methadone or buprenorphine - and offer naxolone to take home with them and training on when/ how to use it
307
What is the second line drug for Opiate Substitution Therapy, and when would it be indicated?
Lofexidine (alpha-2-agonist)
| Indications = rapid detox, mild dependence, preference
308
What is the minimum duration of follow-up care following opiate detoxification?
6 months
309
For how long following last use is cannabis present in urine?
4 weeks
310
Recall some chronic complications of cannabis use
Dysthymia, anxiety/ depressive illness, amotivational syndrome
311
Recall 4 types of hallucinogenic drug
LSD, phencyclidine, ketamine, magic mushrooms
312
How long can an LSD trip last?
12 hours
313
What is a street name for phencyclidine?
Angel dust
314
What are the symptoms of phencyclidine use?
Violent outbursts and ongoing psychosis
315
Recall the symptoms of ketamine use in smaller and larger doses
```
Smaller = dissociation
Larger = hallucinations and synaesthesia
```
316
Recall the symptoms of magic mushroom use in smaller and larger doses
```
Small = euphoria
Large = hallucinations
```
317
What can be used to treat hallucinogen withdrawal short term?
BDZs
318
What stimulant is most often used in East African communities?
Khat/ quat/ chat
319
Which recreational stimulant drug class may cause dependence?
Amphetamines
320
Recall some acute side effects of cocaine use
Arrhythmia, intense anxiety, HTN
321
Recall some chronic side effects of cocaine use
Nasal septum necrosis, foetal damage, panic and anxiety, delusions, psychosis
322
How can ecstasy cause death?
Via dehydration and hyperthermia
323
Recall the 2 phases of cocaine withdrawal
1. Crash phase - depression, agitation, irritability
| 2. Withdrawal - poor concentration, insomnia, slowed movements
324
How long does cocaine remain in urine?
5-7 days
325
What is the most significant risk of BDZ use?
Dependence
326
What is the result of BDZ overdose?
Respiratory depression
327
How should BDZ overdose be treated?
IV flumenazil
328
What are the 2 options for BDZ withdrawal management?
1. Slow-dose reduction
| 2. Switch to diazepam equivalent dose and then slow-dose reduction
329
What is the most common side effect of BDZ withdrawal?
Anxiety
330
At what rate should BDZ dose be reduced?
1/8th dose every 2 weeks
331
What are the 3 medical options for smoking cessation?
Nicotine replacement therapy, varenicline, bupropion
332
What is the mechanism of action of Varenicline and Bupropion?
```
Varenicline = partial nicotine receptor agonist
Bupropion = selective DA and NA reuptake inhibitor (weak)
```
333
How long before the quit date should Bupropion and Varencline be started?
7-14 days
334
Recall some contraindications for varenicline
<18 y/o, renal disease
335
Recall some contraindications for bupropion
<18 y/o, seizures, CNS disorder, eating disorder, BPAD, cirrhosis
336
Recall the 3 Ps necessary to diagnose personality disorder?
Persistent, pervasive and pathological
337
Recall the 3 broad clusters of personality disorders
Cluster A = odd/ eccentric (weird) - paranoid, schizoid, schizotypal
Cluster B = dramatic/ erratic/ emotional (wild) - dissocial, borderline, histrionic, narcissistic
Cluster C = anxious/ fearful (worried) - anankastic, anxious-avoidant, dependent
338
What criteria must be met to diagnose a personality disorder?
REPORT:
R - relationships affected (pathological)
E - enduring (persistent)
P - pervasive
O - onset in childhood (persistent)
R - results in distress (Pathological)
T - Trouble in occupational/ social performance (pathological)
339
What is the supposed prevalence of personality disorder?
10%
340
What are the differences between schizotypal and schizoid personality disorders?
Schizotypal: some positive schizophrenia symptoms = eccentricity, paranoia, social withdrawal and inappropriate affect
Schizoid: just negative schizophrenia symptoms
341
Recall the features of paranoid personality disorder
```
SUSPECT
S - sensitive
U - unforgiving
S - suspicious
P - possessive/ jealous
E - excessive self-importance
C - conspiracy theories
T - tenacious sense of rights
```
342
Recall the features of schizoid personality disorder
ALL ALONE
A - anhedonic
L - limited emotional range
L - little sexual interest
```
A - apparent indifference to praise/ criticism
L - lacks close relationships
O - one-player activities
N - normal social conventions ignored
E - excessive fantasy world
```
343
Recall the features of histrionic personality disorder
```
ACTORS
A - attention-seeking
C - concerned with appearance
T - theatrical
O - open to suggestive
R - racy/ suggestive
S - shallow affect
```
344
Recall the features of emotionally unstable personality disorder
```
AEIOU
A - affective instability
E - explosive behaviour
I - impulsive
O - outbursts of anger
U - Unable to plan/ consider consequences
```
345
Recall the features of dissocial personality disorder
```
FIGHTS
F - Forms, but cannot maintain relationships
I - irresponsible
G - guiltless
H - heartless
T - temper easily lost
S - someone else's fault
```
346
Recall the features of anankastic personality disorder
```
DETAILED
D - doubtful
E - excessive detail
T - tasks not complicated
A - adheres to rules
I - inflexible
L - likes own way
E - excludes pleasure and relationships
D - dominated by intrusive thoughts
```
347
Recall the features of anxious/ avoidant personality disorder
```
AFRAID
A - avoids social contact
F - fears rejection/ criticism
R - restricted lifestyle
A - apprehensive
I - inferiority
D - doesn't get involved unless sure of acceptance
```
348
Recall the features of dependent personality disorder
```
SUFFER
S - subordinate
U - undemanding
F - fears abandonement
F - feels helpless when alone
E - encourages others to make decisions
R - reassurance needed
```
349
What is 'splitting' in personality disorders?
An immature response where a person cannot reconcile the good and bad in someone and only views them as 'good' or 'bad'
350
In which conditions may splitting be seen?
EUPD/ BPD
351
What does 'dissociation' describe in personality disoder?
An immature ego defence where one assumes a differerent identity to deal with a situation
352
What is sublimation?
A mature ego defence where one takes an unacceptable personality trait and uses it to drive a respectable work that does not conflict with their ego/values (i.e. a youth with anger issues signs up to a boxing academy)
353
What is a 'reaction formation' in personality disorder?
An immature ego defence where one supresses unacceptable emotions and replaces them with their exact opposite (eg a gay man becomes a champion of anti-homosexual policy)
354
What is 'identification' in personality disorder?
Modelling the behaviour of someone else (eg child who was abused becomes abuser, or child who has lost younger brother playing with younger brother's toys)
355
What is 'displacement' in personality disorder?
Defence mechanism whereby someone takes out their emotions on a neutral person
356
What is 'projection' in personality disorder?
Where a person assumes an innocent or neutral character is guilty for the patient's actions
357
Which medications might be used in cluster A personality disorders?
None
358
Which medications might be used in cluster B personality disorders?
antipsychotics, antidepressants and lithium
359
Which medications might be used in cluster C personality disorders?
Lithium
360
In which personality disorders is dialetical behaviour therapy particularly useful?
EUPD/BPD
361
What are the 2 concepts introduced by DBT?
Validation (your emotions are acceptable)
| Dialectics (things in life are rarely black and white)
362
Which eating disorder is most genetically heritable?
Anorexia nervosa
363
How can you test for proximal myopathy?
Squat test
364
What is the expetced T4 thyroid measurement in patients with an eating disorder?
Low
365
What ECG abnormality may be present in bulimia nervosa?
Long QT
366
What are some indications for immediate admission in high risk patients with eating disorders?
```
Low BMI (not defined by NICE, but approx <13)
Weight loss of >1kg in a week
Septic-looking signs
HR,40/ long QT
Suicide risk
```
367
What is required for anorexia nervosa diagnosis in the ICD-10?
1. BMI < 17.5
2. Deliberate weight loss
3. "Fear of the fat"
368
How are anorexia nervosa and bulimia nervosa distinguished clinically?
AN = underweight, BN = normal/ increased weight
369
What is Russel's sign?
Callous/ cut knuckles from self-induced vomiting
370
How is anorexia nervosa managed?
NO WATCHFUL WAITING - refer immediately
371
What are the AandE guidelines used for patients with anorexia nervosa?
MARISPAN (Management of Really Sick Patients with AN)
372
At what BMI should someone be referred to Community Eating Disorder Services urgently?
<15
373
Alongside a referral, in what 3 ways should anorexia nervosa be managed by the GP?
1. Engage and educate (eg stop laxative abuse because it doesn't affect calorie intake)
2. Signpost support (eg BEAT, MIND)
3. Treat co-morbid psychiatric illness
374
What are the first line options for treatment of anorexia nervosa in secondary care?
CBT-ED
MANTRA (Maudsley AN Treatment in Adults)
SSCM (Specialist Supportive Clinical Management)
375
What is the duration of CBT-ED?
40 weekly sessions
376
What is the focus of MANTRA therapy for anorexia nervosa?
Focusing on the cause of the anorexia nervosa
377
Describe SSCM treatment for anorexia nervosa
Explore problems of anorexia, educate on nutrition and eating habits, explore a future beyond anorexia
378
What is the target weight gain range for AN patients?
0.5-1.0kg/ week
379
When should pharmacological managemrnt be used in AN?
If physical symptoms, rapid weight loss or BMI <13.5
380
What is the appropriate drug for pharmacological treatment of AN?
Fluoxetine
381
What are the first and second line treatments for children with AN?
1st line = family therapy
| 2nd line = ED-CBT
382
What is the main defining feature of the Refeeding Syndrome?
Low phosphate
383
What is the aetiology of the refeeding syndrome?
Intracellular shift in (already low) ions due to insulin release upon refeeding
384
Which electrolytes are low in the refeeding syndrome?
Low K+, low phosphate, low magnesium
385
What screening questionnaire can be used to screen for anorexia as well as bulimia?
SCOFF:
Do you ever make your self SICK because you feel uncomfortably full?
Do you worry you have lost CONTROL over how much you eat?
Have you recently lost more than ONE stone in a 3-month period?
Do you believe yourelf to be FAT when others say you're too thin?
Would you say that FOOD dominates your life?
386
What are the criteria for diagnosing BN?
Must have all 3 of:
1. Binging/ irresistable craving for food
2. Purging behaviours
3. Psychopathology (feeling loss of control. Morbid dread of fatness)
387
What is BED?
Binge eating disorder - most common ED, does not include purging pathology
388
How should bulimia nervosa be managed?
Like anorexia, refer immediately and screen for immediate admission (most are managed in the community)
389
How should bulimia nervosa be managed by the GP alongside referral?
1. Treat medical complications (eg do a regular dental review)
2. Treat co-morbid psychiatric illness
3. For moderate to severe BN, use SSRIs high dose (fluoxetine)
390
Differentiate between dissociative disorder and somatisisation disorder
DD = disorders of physical functions under voluntary control and loss of sensation
SD = disorders involving pain or autonomically-controlled sensations
391
What is dissociative fugue?
Dissociative amnesia + purposeful travel beyond everyday range
392
What is a dissociative stupor?
Lack of voluntary movement/ normal responses to external stimuli
393
What are trance and posession disorders?
Temporary loss of personal identity and full sense of awareness of surroundings
394
What part of the body is affected by dissociatve motor disorders?
Limbs
395
How can dissociative convulsions be distinguished from an epileptic seizure?
Tongue-biting, bruising from falls and incontinence are rare
A real seizure will raise prolactin, but a dissociative seizure will have a normal post-ictal prolactin
396
How can dissociative anaesthesia be distinguished from organic anaesthesia?
Areas of anaesthesia do not follow normal dermatomal distribution
397
How is somatisation defined?
Multiple, recurrent and frequently changing physical symptoms of 2 years duration without evidence of underlying organic cause
398
Recall the 4 subtypes of somatisation disorder
1. Undifferentiated somatoform disorder
2. Hypochondrial disorder
3. Somatoform autonomic dysfunction
4. Persistent somatoform pain disorder
399
What are the hallmark features of hypochondrial disorder?
Often cancer
| Pre-occupation with a single problem
400
What is somatoform autonomic dysfunction?
Symptoms presented as if due to an ANS-controlled system (eg CVS, GIT, Resp) with ANS arousal (eg palpitations, sweating, flushing, tremor) + subjective non-specific symptoms (pain/ burning)
401
What is the age-limit for early-onset dementia?
65 years old
402
What are the 2 most useful screening questionnaires for dementia?
AMTS, GPCOG
403
What AMTS score suggests cognitive impairment?
<7
404
What is the most detailed assesment of possible dementia?
Addenbrooke's (ACE-R) - 100 questions
405
How many questions are in the MMSE?
30
406
What would be the appearance on MRI of a brain affected by Alzheimer's?
Grey matter atrophy, wide ventricles and sulci, temporal lobe atrophy
407
What biomarker can be used to identify Lewy Body dementia?
123|-FP-CIP SPECT
408
What are the 3 theories of Alzheimer's aetiology?
Amyloid (beta secretase replaces alpha secretase --> toxic aggregates that form A-Beta protein)
Tau (hyperphosphorylated tau is insoluble)
Inflammation (to do with CNS macrophages)
409
Which region of the brain is the first to be affected by Alzheimer's disease?
hippocampus
410
Recall 4 genetic risk factors for Alzheimer's
Presenelin 1
Presenelin 2
Beta-amloid precursor protein gene
Co-existent Downs syndrome
411
What are the 4 key elements of pathophysiology in Alzheimer's?
Atrophy from neuronal loss
Plaque formation
Neurofibrilliary tangles
Cholinergic loss
412
How does Alzheimer's characteristically present?
The 4 'A's:
- Amnesia
- Aphasia
- Agnosia
- Apraxia
413
If a short-term antipsychotic is required in Alzheimer's disease, which is most appropriate?
Risperidone
414
Recall the options for medical management of Alzheimer's
```
1st line (mild-moderate) = anticholineesterases: donezepil/ galantamine/ rivastigmine
2nd line (moderate - severe) = memantine - a NMDA (glu) partial receptor agonist
```
415
What is the first line option for psychological management of Alzheimer's?
Structural group cognitive stimulation
416
What checks should be done before anti-cholineesterase prescription?
1st = ECG
Check medications: absolute contraindications are anticholinergics, beta-blockers, NSAIDs and muscle-relaxants
Relative contra-indications = asthma, COPD, GI disease, braadycardia, AV block
417
What is the common presentation of vascular dementia?
Step-wise decline that starts with emotional/ personality changes (including labile emotion) and deteriorates to produce cognitive deficit
418
How should vascular dementia be managed?
```
Manage RFs (daily aspirin, dietary advice, stop smoking etc)
Same psychological treatment as alzheimer's dementia
```
419
What are Lewy bodies composed of?
Alpha synuclein with ubiquitin
420
Describe the distribution of Lewy bodies in Lewy Body Dementia vs Parkinsons disease
LBD = brainstem, cingulate gyrus and neocortex
| In PD = just brainstem
421
Describe the classical presentation of Lewy body dementia
Fluctuating confusion with marked variations in alertness levels
422
What confusing symptoms may be seen in Lewy body dementia?
Lilliputian hallucinations (like delirium)
Parkinsonianism
Frequent falls
423
What is an important medication NOT to offer in Lewy body dementia?
Antipsychotics - they increase risk of cerebrovasvular disease
424
What medical management can be used in Lewy body dementia?
Same as Alzheimers disease - anti-cholineesterases
425
What is another name for frontotemporal dementia?
Pick's disease
426
What is especially unusual about frontotemporal dementia?
Early onset (usually 40 to 60 years)
427
Recall the signs and symptoms of frontotemporal dementia
1. Frontotemporal symptoms (disinhibition, personality changes)
2. Semantic dementia (progressive loss of understanding of verbal and visual meaning)
3. Progressive non-fluent aphasia (1st they get naming difficulties, this progresses to mutism)
428
What two investigations are most useful in frontotemporal dementia?
FDG-PET (fluorodeoxyglucose), MRI (to see frontal lobe shrinkage)
429
What is the prognosis for frontotemporal dementia?
Death in 5-10 years
430
What is the inheritance pattern of Huntingdon's?
Autosomal dominant so 50% chance of children inheriting
431
When in the life-course is the onset of Huntingdon's?
30-50 years old
432
What is the general clinical picture of Huntingdon's?
Clumsy, speech difficulties
433
Recall some signs and symptoms of Huntingdon's
Movement: chorea, slurred speech, stumbing/ clumsiness
Cognitive: difficulty organising, learning, being flexible
Psychiatric - depression, irritability, suicide in 9%
434
What are chorea?
Involuntary jerking movement that tend to flow from one area to another
435
What is the model for formulation in CAMHS?
Biological, psychological and social for the 4 'P's: predisposing, precipitating, perpetuating and protecting
436
What are the ICD-10 criteria for diagnosis of ADHD?
Impaired attention and overactivity, present prior to 6 years of age, of long duration, and present in
two or more settings
437
What rating scale can be used to asses ADHD?
Conner's Comprehensive Behaviour Rating Scale (age 6-18)
438
How should ADHD be managed?
MDT focused
1st line: consider watchful waiting for up to 10 weeks - refer to specialist if severe symptoms > 10 weeks
If child is under 5:
- 1st line = ADHD-focused group parent-training programme
- 2nd line is referral to a specialist service
```
If child is over 5:
- 1st line = same (ADHD-focused group parent-training programme)
- 2nd line = referral and medications if ADHD persists
Medications:
- 1st line: methylphenidate
- 2nd line: lisdexaphetamine
- 3rd line: dexaphetamine
- 4th line: atomoxetine
```
439
What are some side effects of methylphenidate?
Abdo pain, nausea, dyspepsia
440
Recall some important things to monitor whilst giving ADHD medication
1. Weight every 3 months (if <10 yo) or every 6 months (>10 yo)
2. Measure height, HR and BP (as meds may cause interruptions to growth)
441
What % of children with ADHD have it as an adult?
15%
442
What medication during pregnancy can increase risk of Autism spectrum disorder?
Sodium valporate
443
Recall 4 important associations of ASD
Fragile X syndrome
Tuberous sclerosis
Neurofibromatosis
Di-George
444
What is the difference between Asperger's and Autism?
Asperger's has no delay in language/ cognitive development
445
What is Rett syndrome?
Medical disorder that affects girls > boys: X-linked, MECP2 gene - develop normally until about 2 y/o then sudden deterioration and less social interaction - constantly moving hands
446
What is the most common form of ASD?
Pervasive Developmental Disorder Not Otherwise Specified (PPD-NOS)
447
In what 3 spheres of life are there abnormalities in Autistic spectrum disorder?
Social interaction
Communication
Patterns of behaviour/ interests/ activities
448
What are the typical motor mannerisms of children with ASD?
Finger flapping and repetitive whole-body movements
449
Recall a simpler easy diagnostic triad for ASD
Deficits in:
1. Verbal and non-verbal communication
2. Reciprocal social interaction
3. Restrictive or repetitive behaviours/ interests
450
What is one hallmark symptom of Autism spectrum disorder?
Echolalia
451
Recall the 2 gold standard diagnostic tools for ASD
1. ADI-R (autism diagnostic inventory - revised)
| 2. ADOS (Autism Diagnostic Observatory Schedule)
452
Describe the management of Autistic spectrum disorder
MDT-based
1st line = play-based interventions (play specialists) and SALT doing reciprocal communication exercices
If challenging behaviour:
- psychosocial assesment: reduce impairment in communication (eg visual aids), treat co-existing physical disorders
453
Define conduct disorder
Repetitive and persistent pattern of antisocial behaviour which violates basic rights of others that are not in line with age-appropriate social norms
454
In which age group can oppositional defiant disorder exist?
<10 years old
455
For how long must symptoms persist for a diagnosis of conduct disorder?
6 months
456
How should conduct disorder be managed?
1st line = parent management training programme (eg Webber-Stratton, Triple-P)
If parental engagement is weak, try:
2nd line = child individual or group interventions focussed on problem-solving and anger management
457
By what 3 criteria is learning difficulty defined?
IQ < 70, impaired social/ adaptive functionning, onset in childhood
458
At what IQ level is the cause of LD considered to be always organic?
IQ <50
459
What is the most prevalent physical symptom of learning difficulties?
Poor sleep/ wake cycle
460
What scale is used to assess intellectual impairment?
WAIS II
461
What medications might be useful in learning difficulties?
Melatonin for sleep
462
Which law protects reasonable adjustment?
Disability act 1995
463
Which MMSE scores indicate no impairment/ mild impairment/ severe impairment?
24-30 - No cognitive impairment
18-23 - Mild cognitive impairment
0-17- Severe cognitive impairment
464
In anorexia nervosa, which things will be high on a blood test?
G's and C's raised: growth hormone, glucose, salivary Glands, cortisol, cholesterol, carotinaemia
465
How long after a change in lithium dose should the levels be taken?
7 days later and 12 hours following last dose
466
What electrolyte abnormality is associated with SSRIs?
Hyponatraemia
467
What is the anti-depressant of choice following a myocardial infarction?
Sertralline
468
What is acute dystonia?
Sustained muscle contraction (eg oculogyric crisis, torticollis)
469
How can acute dystonia be managed?
Procyclidine
470
What is acute dystonia a side effect of?
Antipsychotics (typical and atypical alike)
471
What is the most common endocrine disorder developing as a result of chronic lithium toxicity?
Hypothyroidism
472
What is the main risk of using paroxetine in pregnancy?
Congenital malformations
473
Which antipsychotic reduces the seizure threshold?
Clozapine
474
What drug can be used to treat tardive dyskinesia?
Tetrabenazine
475
What is the main risk of SSRI use in the third trimester of pregnancy?
Persistent pulmonary hypertension of the newborn
476
What are the metabolic side effects of antipsychotics?
Hyperlipidaemia
| Diabetes mellitus
477
How should antidepressant medication be managed prior to ECT treatment?
The dose should be reduced but not stopped
478
What is the most prominent symptom of SSRI-discontinuation syndrome?
Diarrhoea
479
What type of incontinence can be caused by TCAs?
Overflow incontinence
480
Which psychiatric drug can cause hyperparathyroidism?
Lithium
481
Which antipsychotics can be given as a long-acting depot injection, and which of these are typical vs atypical antipsychotics?
Typicals: Zuclopenthixol is the main one (Clopixol), also flupentixol
Atypicals: Risperidone
482
How can you differentiate the NMS with serotonin syndrome based on the neuromuscular abnormalities they produce?
NMS: reduced activity ('lead pipe' rigidity, dysphagia/ dyspnoea due to pharyngeal stiffness)
SS: Increased activity (myoclonus/ clonus, hyperreflexia, tremor, less severe muscular rigidity than the NMS)
483
How do bromocriptine and dantrolene work to treat the NMS?
Bromocriptine reverses dopamine blockade
Dantrolene reduces muscle spasm
ECT
