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THURSDAY Year 5 Specialties Ludley's (COPY) > ICSM Year 5 Psychiatry > Flashcards

ICSM Year 5 Psychiatry Flashcards

1
Q

What are the 4 types of auditory hallucination?

A
  1. Thought echo (pt’s thoughts are projected out loud)
  2. 3rd person voices
  3. Running commentary
  4. Command
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2
Q

What is a reference delusion?

A

Patient believes unsuspicious thing has reference to them, eg. TV programme dialogue refers to them

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3
Q

Recall the 3 types of thought disorder

A

Insertion, withdrawal and broadcasting

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4
Q

What is Cotard’s syndrome?

A

Nihilistic delusion in which pt believes they are rotting/ dead - can occur in severe depression

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5
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

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6
Q

What is the maximum duration of each of the non-emergency sections of the MHA?

A

Section 2: 28 days
Section 3: 6 months
Section 5(2): 72 hours
Section 136: 24-36 hours

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7
Q

What is the requirement for recommendation for detainment under each of the non-emergency sections on the MHA?

A 
Sections 2 and 3 = 2 doctors, with at least one being Section 12 approved
Section 5(2) = 1 doctor
Section 136 = a police officer
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8
Q

Under what section of the MHA is emergency treatment undertaken, and who may apply for it?

A

Section 4 - it only needs ONE doctor because it’s an emergency and the doctor MUST be S12 approved (a psychiatrist)

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9
Q

Who may apply for section 2/3 detainment under the MHA?

A

AMHP (approved mental health professional) or NR (nearest relative)

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10
Q

Who may apply for discharge from a section 2 MHA detention?

A

NR or Mental Health Review Tribunal (MHRT) within first 14 days of detention
OR
At any time: by the responsible clinician

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11
Q

Recall the process for forcibly medicating someone under the MHA

A

Under Section 3 can be forcibly medicated for 3 months, if then not consenting, need a SOAD assesment (second opinion appointed doctor)

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12
Q

What qualification is required for someone to detain a patient under Section 4 of the MHA?

A

Must be a psychiatrist

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13
Q

What does section 5(4) of the MHA allow?

A

Detention of an inpatient by a nurse

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14
Q

What is the maximum duration of detention under section 5(4) of the MHA?

A

6 hours (detention by nurse)

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15
Q

What does section 17 of the MHA allow?

A

Allows leave from a current section, but is not permanent discharge

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16
Q

What does section 35 of the MHA permit?

A

Assessment of a patient accused of committing a crime

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17
Q

How long does assesment last under section 35?

A

28 days

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18
Q

What are the appeal requirements to section 35 of the MHA?

A

You can’t appeal

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19
Q

What does section 37 of the MHA permit?

A

Treatment of a convicted criminal - otherwise like section 3

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20
Q

What are the appeal requirements to section 37 of the MHA?

A

Within 21 days to court, after 6 months to the MHRT (mental health review tribunal)

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21
Q

What section of the MHA is applied for by the Crown Court?

A

Section 41 - a restriction order

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22
Q

Under which section of the MHA can a serving prisoner be transferred to hospital?

A

Section 47 - when restriction is added = section 49

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23
Q

What is a community treatment order?

A

Discharge from a previous section providing certain conditions are met - requires renewal every 6 months

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24
Q

Describe the role of the Approved Mental Health Professional

A

95% are social workers, and are responsible for coordinating the assessment and admission of a patient to hospital if needed

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25
Q

Describe the role of the Independent Mental Health Advocate

A

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

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26
Q

What does DoLS stand for?

A

Deprivation of Liberty Safeguards (within MCA 2005) - which can be within a carehome or hospital

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27
Q

What is the mechanism of action of most antipsychotic drugs vs clozapine?

A

Dopamine receptor antagonists - most block D2 but Clozapine blocks D1 and D4

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28
Q

Recall some common side effects of anti-psychotics

A

Extrapyramidal - dystonia/ akathisia/ parkinsonisms/ tardive dyskinesias (more common in typicals)

Hyperprolactinaemia (galacorrhoea, amenorrhoea, gynaecomastia)

Weight gain

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29
Q

Why do atypical antipsychotic drugs have fewer side effects than typicals?

A

More selective (just antagonise D2 and 5-HT2 receptors)

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30
Q

What class of drug is the first line treatment in schizophrenia?

A

Atypical antipsychotic

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31
Q

What class of drug is the first line treatment in relapsed schizophrenia?

A

Typical antipsychotic

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32
Q

In the elderly, what extra risk do antipsychotic drugs carry?

A

Increased risk of stroke and VTE

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33
Q

Describe how the dosage of clozapine is controlled

A

Start low and titrate up slowly, if >48 hours missed medication, need to start again

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34
Q

Recall one caution of using clozapine

A

If patient stops smoking suddenly, the clozapine levels will suddenly go up

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35
Q

Recall 2 examples of typical antipsychotics

A

Haloperidol, chlorpromazine

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36
Q

Recall 4 examples of atypical antipsychotics

A

Clozapine, risperidone, apiprazole, olanzapine, quetiapine

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37
Q

Recall one significant side effect to remember of clozapine

A

Agranulocytosis (1%)

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38
Q

Recall one drug interaction of clozapine

A

Lithium

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39
Q

What is neuroleptic malignant syndrome?

A

A major side effect of antipsychotics characterised by fever, altered mental status, muscle rigidity, and autonomic dysfunction

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40
Q

What is akathisia?

A

An unpleasant subjective feeling of restlessness

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41
Q

What is tardive dyskinesia?

A

Rhythmic involuntary movements of the mouth, face, limbs and trunk

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42
Q

Describe the monitoring process for patients who take antipsychotic medications

A

Basic obs + bloods (more frequent for clozapine) + assessment of movement disorders, nutritional status and physical activity + ECG if CVD risk factors present

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43
Q

When should an FBC be done in a patient taking clozapine?

A

At frequent intervals for monitoring + every time there’s an infection as need to check there’s no agranulocytosis

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44
Q

Recall the symptoms of suddenly stopping antidepressant medication

A 
FIRM STOP
Flu-like symptoms
Insomnia
Restlesness
Mood swings

Sweating
Tummy problems
Off-balance (ataxia)
Paraesthesia

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45
Q

Recall 4 examples of SSRIs

A

For Sadness, Panic, Compulsion:

Fluoxetine, sertraline, paroxetine, Citalopram

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46
Q

For approx how long do SSRIs make someone feel worse before they feel better?

A

1-2 weeks

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47
Q

Recall one important risk of SSRIs

A

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

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48
Q

Recall one important interaction of SSRIs

A

Triptans - interaction can cause serotonin syndrome - so ask about migraines

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49
Q

Recall one important side effect of citalopram

A

QT prolongation

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50
Q

Recall one important side effect of sertraline

A

Can cause arrhythmias and QT prolongation - but still the antidepressant of choice following an MI (this was asked in a PPQ so nb)

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51
Q

Recall the main side effects of all SSRIs

A 
The 5 'S's: 
Suicidal idealisation
Stomach (weight gain, DNV)
Sexual dysfunction
Sleep (insomnia)
Serotonin syndrome
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52
Q

When prescribing an SSRI for anxiety, how long should you advise the patient it may take to work?

A

Anxiety may initially worsen, will need 4-6 weeks to work

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53
Q

How long should SSRI medications be continued for?

A

6 months after remission of first episode, 2 years after remission if it’s a recurrence - gradually stop over 4 weeks

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54
Q

Recall 3 drugs that should be avoided in suicide risk, and 2 that are particualrly useful when there is a suicide risk

A

Avoid: TCAs, MAOIs, Venlafaxine - lethal in OD

Use: SSRIs (despite INITIAL suicide risk) or mirtazapine

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55
Q

How should different SSRI medications be switched?

A

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

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56
Q

What does SNRI stand for?

A

Serotonin-noradrenaline reuptake inhibitor

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57
Q

What is the main side effect of SNRIs?

A

Headache

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58
Q

Recall 2 examples of SNRIs

A

Venlaxafine, duloxetine

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59
Q

Describe the side effects of SNRIs

A

Same ‘5S’ as SSRIs but also constipation, HTN + raised cholesterol

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60
Q

What is the mechanism of action of TCAs?

A

Block serotonin and NA reuptake

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61
Q

What can TCAs be used for at low vs high doses?

A

Low dose: blocks H1 and 5HT and aids sleep

Higher doses: blocks all receptors and is used in depression

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62
Q

Why are TCAs not given if there is risk of suicide?

A

Can be fatal in OD

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63
Q

What is one key contraindication for TCAs?

A

If patient is also taking a monoamine oxidase inhibitor

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64
Q

Recall the side effects of TCAs

A

TCA: Thrombocytopenia
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

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65
Q

What are the anticholinergic side effects that are possible with all types of antidepressant?

A

“Can’t see, can’t pee, can’t spit, can’t shit”

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66
Q

Give 2 examples of TCAs

A

Amitriptyline, clomipramine

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67
Q

What type of antidepressant is mirtazapine?

A

noradrenergic and specific serotonin antidepressant (NaSsA)

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68
Q

What is the most common side effect of mirtazapine?

A

Weight gain

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69
Q

When is mirtazapine indicated?

A

Triad of depression + insomnia + loss of appetite

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70
Q

Give 2 examples of MAOI antidepressants

A

Phenelzine, selegiline

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71
Q

What does MAOI stand for?

A

MonoAmine Oxidase Inhibitor

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72
Q

What is the main risk of MAOI use?

A

Hypertensive cheese reaction

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73
Q

What type of antidepressant is moclobemide?

A

Reversible Inhibitor of Monoamine oxidase A (RIMA)

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74
Q

What is the max length of prescription for a BDZ drug?

A

2-4 weeks

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75
Q

What is the mechanism of action of BDZs and BARBs?

A

Enhance GABA transmission at GABA-A receptor

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76
Q

How does the mechanism of action of BDZs and BARBs differ?

A

BDZ increases duration of receptor opening, BARB increases frequency of opening

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77
Q

Why are barbiturates more dangerous than BDZs?

A

Less selective so more excitatory transmission

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78
Q

Give 3 examples of long-acting benzodiazepene medications, and what these are useful for

A

Diazepam, lorazepam, chlordiazepoxide

Useful as an anxiolytic, in delirium tremens/ acute alcohol withdrawal

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79
Q

What is the difference between a sedative and a hypnotic drug?

A

Sedative reduces physical + mental activity without producing a loss of consciousness, whereas hypnotic will induce sleep

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80
Q

Give 2 examples of short-acting BDZs and recall their main clinical use

A

Teazepam, oxazepam - used as sedatives

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81
Q

What is a Z drug used to treat?

A

Treats insomnia (similar to a BDZ)

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82
Q

Give an example of a Z drug

A

Zopiclone

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83
Q

When should Z drugs be used?

A

Only when insomnia is severe and disabling

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84
Q

What is a key side effect of zopiclone?

A

Increased risk of falls

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85
Q

Describe the withdrawal process from zopiclone

A

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

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86
Q

What is the antidote to zopiclone, and its mechanism of action?

A

Flumenazil (BDZ antagonist)

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87
Q

Why should zopiclone not be used in pregnancy?

A

Can cause a cleft lip

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88
Q

What are stimulants used to treat?

A

ADHD and narcolepsy

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89
Q

Give 2 examples of stimulant drugs used to treat ADHD

A

Methylphenidate (Ritalin)

Dexaphetamine

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90
Q

What is the mechanism of action of stimulant drugs used in ADHD?

A

Potentiate the effect of monoamine neurotransmitters (DA, NA, 5HT)

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91
Q

Recall some side effects of stimulant drug use

A

Cardiac pathology, drug-induced psychosis, appetite suppression, “risky” behaviour, insomnia, impulsivity

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92
Q

What are mood stabilising drugs used to treat?

A

BPAD, schizoaffective disorder

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93
Q

What are the 4 main mood stabilising drugs?

A

Lithium (1st line), valporate (2nd line), carbamazapine, lamotrigine

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94
Q

Recall 4 key side effects of lithium

A

Mild tremor, hypothyroidism, eyebrow hair loss, nephrogenic DI

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95
Q

How does a lithium OD present?

A 
Tremor 
Ataxia
GI disturbance/ urinary symptoms
Seizures 
AKI
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96
Q

What regular monitoring should be done in lithium prescription?

A

Every 3 months: lithium levels, every 6 months: UandEs and TFTs

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97
Q

Why should lithium not be used in pregnancy?

A

Causes Ebstein’s abnormality (heart defect)

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98
Q

Recall 2 key side effects of valporate

A

Hair loss + weight gain

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99
Q

What is the main risk of using valporate in pregnancy?

A

Spina bifida - do not prescribe to a woman of child-bearing age unless a pregnancy prevention programme is in place

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100
Q

What is the main risk of using carbamazipine in pregnancy?

A

Spina bifida

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101
Q

What is the key side effect of lamotrigene use?

A

Severe skin rash - SJS

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102
Q

What is the most likely drug to cause the neuroleptic malignant syndrome?

A

Haloperidol

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103
Q

Recall the symptoms of the NMS

A

Gradual onset triad of mental status change (catatonia), muscular rigidity + autonomic instability (hyperthermia + labile BP)
“MMA” fighters are muscular, mental and (autonomically) unstable

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104
Q

In what time frame does the NMS develop?

A

4-11 days after starting any antipsychotic medication

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105
Q

What investigations should be done to identify NMS?

A

FBC (to show leucocytosis), UandEs (show high CK and AKI)

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106
Q

How should the NMS be managed?

A
  1. ABC
  2. AandE/ITU admission
  3. Stop antipsychotics
  4. Supportive (fluids, dialysis etc to deal with AKI)
  5. Dantrolene, bromocriptine
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107
Q

Recall the symptoms of the serotonin syndrome

A

Abrupt onset triad of mental state change, neuromuscular changes and autonomic instability (so very similar to NMS but abrupt onset rather than gradual)

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108
Q

What symptom is likely to present in the serotonin syndrome but not the NMS?

A

Diarrhoea and Vomiting

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109
Q

How does management differ in the serotonin syndrome compared to the NMS?

A

All the same except the drug used is a BDZ (clonazepam) rather than dantrolene and bromocriptine

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110
Q

How does ECT work?

A

Induces a generalised tonic-clonic seizure under general anaesthetic

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111
Q

What are the indications for ECT?

A

ECT:
Euphoric (manic episodes)
Catatonia (not moving in an unusual position)
Tearful (severe depression that is life-threatening)

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112
Q

What is an absolute contraindication for ECT?

A

Raised intracranial pressure

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113
Q

What are the short term side effects of ECT?

A

Headaches and nausea, muscle aches, cardiac arrhythmia, retrograde amnesia (loss of memories before the ECT)

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114
Q

What is the main target of CBT?

A

So-called ‘Negative Automatic Thoughts’

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115
Q

What is Beck’s negative cognitive triad

A

Self-perpetuating triad of:

  • Negative self-view
  • Negative future view
  • Negative world view
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116
Q

Describe the negative cycle that CBT aims to tackle

A

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”)

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117
Q

Recall the name of 2 CBT methods used to tackle negative thought patterns

A

Longitudinal format/ hot-cross bun methods

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118
Q

Describe the longitudinal format of CBT

A
  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
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119
Q

What is the theoretical basis of psychodynamic psychotherapy?

A

Problems are shaped by childhood experiences –> causes conflict between conscious and unconscious mind, therapy reveals unconscious mind

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120
Q

What is the difference between psychoanalytics and psychodynamics?

A 
Psychoanalytics = internal conflicts
Psychodynamics = interpersonal conflicts
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121
Q

How does the aim of psychodynamic psychotherapy differ from CBT primarily?

A

Aims to change personality and emotional development, rather than aiming to understand thoughts and see how that impacts the individual

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122
Q

Recall 4 protective factors against suicide

A

Married, lithium medication, faith, no substance abuse

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123
Q

What is the reversing agent for overdose on a BDZ?

A

Flumenazil

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124
Q

What is the reversing agent for overdose on a Z drug?

A

Flumenazil

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125
Q

What is the reversing agent for overdose on an opiate?

A

Naloxone

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126
Q

What is the reversing agent for overdose on paracetamol?

A

N-acetylcysteine

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127
Q

What is delirium?

A

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

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128
Q

What are the most important differentials to consider in delirium?

A

Infection, medication and constipation but there are SO MANY causes, look for many and don’t be satisfied with one

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129
Q

How is delirium diagnosed?

A

Confusion Assesment Method

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130
Q

How is delirium managed?

A

Modify risk factors, exclude diagnosed dementia, treat the causes

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131
Q

What is the medical management of delirium?

A

PO antipsychotics, AVOID anticholinergics

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132
Q

What is the prognosis for delirium?

A

37% die within 6 months, only 25% have a clinically important recovery in ADLs

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133
Q

What drug can be used IM to rapidly tranquilise if the individual refuses PO medications?

A

IM lorazepam

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134
Q

Recall 3 things that are important to consider before the administration of rapid tranquilisation

A
  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?
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135
Q

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?

A

PO medication (not IM)

Unknown/naïve pt: lorazepam

Known/confirmed antipsychotic use: lorazepam/ olanzapine/ haloperidol AND promethazine (acronym = Lots Of Hallucinations and Panic)

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136
Q

How long should be left to assess a patient’s response to oral tranquilisation?

A

1 hour at least

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137
Q

What is the convention for IM tranquilisation in an unknown/ neuroleptic naïve patient?

A
  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)

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138
Q

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?

A

Presence/ absence of cardiac disease

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139
Q

What is the convention for administering IM tranquilisation in a known patient with NO cardiac disease?

A

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

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140
Q

What is the convention for administering IM tranquilisation in a known patient WITH cardiac disease?

A
  1. Lorazepam - wait 30 mins for response OR olanzapine (repeat if partial response)
  2. If no response: wait 1 hour, then give lorazepam/ olanzapine
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141
Q

Recall the dosing for oral rapid tranquilisation medications

A

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)

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142
Q

Recall the dosing for IM rapid tranquilisation medications

A

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)

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143
Q

Describe how rapid tranquilisation should be monitored

A

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

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144
Q

What are the 2 core symptoms of depression?

A

Low mood + anhedonia

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145
Q

What are the adjunct symtpoms of depression?

A 
Fatigue
Insomnia
Concentration problems
Appetite change
Suicidal thoughts/ acts
Agitation/ slowing of movements
Guilt
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146
Q

Recall 3 medications that may cause depression

A

Steroids, COCP, propranalol

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147
Q

What is dysthymia?

A

Subthreshold depression (2-5 symptoms) of depression for at least 2 years

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148
Q

What is atypical depression?

A

Just somatic symtpoms (weight gain, hypersomnia)

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149
Q

What can improve the symptoms of anxiety-induced insomnia?

A

Mood is increased by increased sleep and eating

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150
Q

What is a depressive stupor?

A

Such extreme psychomotor retardation that the individual grinds to a halt

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151
Q

Recall the roles of the different monoamines, which are reduced in depression

A

Noradrenaline (mood, energy)
5-HT/serotonin (sleep, appetite, memory, mood)
Dopamine (psychomotor activity, reward)

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152
Q

How would you go about investigating for depression?

A

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)

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153
Q

Describe the MSE

A

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)

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154
Q

How is depression treated in children and young people?

A

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

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155
Q

How is depression treated in adults?

A

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

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156
Q

What is the first line antidepressant medication?

A

SSRIs (sertraline, citalopram, fluoxetine, paroxetine)

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157
Q

When should a second line antidepressant be tried?

A

After trying 2 different SSRIs

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158
Q

What is the second line antidepressant medication?

A

SNRIs (venlaxafine, duloxetine)

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159
Q

Recall the stepped increase of dose of venlaxafine

A

37.5mg BD –> 75mg BD –> 75mg morning, 150mg evening

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160
Q

What is the indication for 3rd line antidepressant treatment?

A

If they are resistant to treatment, you can’t augment treatment with further medication

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161
Q

What are the 3rd line treatment options for depression medication?

A

Antipsychotic (eg quetiapine), lithium, or other antidepressant eg mirtazapine

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162
Q

What is the ideal blood level of lithium?

A

0.6-1.0 (toxicity at >2.0)

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163
Q

In which scenario is mirtazapine most useful?

A

When symptoms of insomnia and appetite reduction are evident and debilitating

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164
Q

Describe the side effect profile of sertraline

A

Smallest side-effect profile, so a good one to give to people with comorbid IHD

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165
Q

What is the best antidepressant to give to children?

A

Fluoxetine

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166
Q

What is the most common use of paroxetine?

A

For major depressive episodes

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167
Q

When should paroxetine not be used and why?

A

Pregnancy: in 1st trimester may cause congenital heart defects, in 3rd trimester may cause persistent pulmonary HTN

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168
Q

How can you differentiate between psychotic depression and schizophrenia in the history?

A

“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

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169
Q

How is BPAD defined in the ICD-10?

A

> /= 2 episodes, 1 must be manic, mania lasts around 4 months, depression lasts around 6 months, there is complete recovery between 2 episodes

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170
Q

How can a manic episode be identified?

A

It’s more associated with irritability than elevated mood - they may have grandiose delusions, flight of ideas, over-optism OR suicidal ideas

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171
Q

How is mania diagnosed?

A

Need at least 3 characteristcs of mania on the MSE, lasting at least 7 days and causing an impaired occupational/ social functioning +/- psychosis

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172
Q

What is hypomania?

A

> 3 characteristics of mania lasting at least 4 days, no impairment of functioning, no delusions/ psychosis

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173
Q

What is the difference between type 1 and type 2 BPAD?

A

Type 1 has proper manic episodes, type 2 has recurrent depressive episodes with less prominent hypomanic episodes

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174
Q

What is rapid cycling BPAD?

A

More than 4 episodes per year

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175
Q

What is the best treatment for rapid cycling BPAD?

A

Sodium valporate - they respond well

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176
Q

How much is BPAD risk increased by a 1st degree relative having BPAD?

A

7 fold

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177
Q

What is the rating scale used to investigate BPAD?

A

Young mania rating scale

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178
Q

Why can BPAD be hard to pick up on?

A

Most BPAD patients present in their depressive episodes, so you always need to ask about mania symptoms

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179
Q

Recall some differentials for BPAD?

A

Organic: drugs, dementia, frontal lobe disease, delirium, cerebral HIV
Schizophrenia
Cyclothymia (persistent mild mood instability - never severe enough to cause BPAD/ depression)
Puerperal disorders

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180
Q

How should the urgency of referral be judged in suspected BPAD?

A

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

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181
Q

How should acute mania be treated?

A

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

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182
Q

How should mania be managed in the longterm?

A

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

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183
Q

How do you manage BPAD if they have comorbid depression?

A

You can’t use antidepressants alone as they may cause mania!
Try first: fluoxetine and olanzapine
Seond try quetiapine alone

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184
Q

What is the use of psychological therapies in BPAD?

A

May improve compliance with medication long term

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185
Q

What is the prognosis for BPAD?

A

15% willl commit suicide, but lithium reduces this to same level as general population

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186
Q

How does the ICD-10 define schizophrenia?

A

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

187
Q

Describe the progression of schizophrenia

A
  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
188
Q

What is wavy flexibility?

A

They will retain any shape you put them into!

189
Q

What is the most common subtype of schizophrenia?

A

Paranoid schizophrenia

190
Q

What are the different subtypes of schizophrenia, and how are they characterised?

A

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

191
Q

How does cannabis use increase risk of schizophrenia?

A

Val allele encoding COMT insead of Met allele in non-smokers

192
Q

What rating scale is used to investigate schizophrenia?

A

Brief psychiatric rating scale

193
Q

What type of prescription drug use may cause symptoms of schizophrenia?

A

Steroids

194
Q

What is schizoaffective disorder?

A

Schizophrenic and affective symptoms develop together and are balanced

195
Q

What is schizotypal disorder?

A

Eccentricity with abnormal thoughts

196
Q

By what teams should schizophrenia be managed in an urgent emergency?

A

Crisis Resolution Team and Home Treatment Team

197
Q

By which team should schizophrenia be managed when it is not urgent?

A

Early Intervention in Psychosis (EIP) team

198
Q

Recall the stepwise biological treatment of schizophrenia

A

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

199
Q

Recall the psychological treatment of schizophrenia

A

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

200
Q

Recall the community monitoring that is important when treating someone for schizophrenia

A
  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
201
Q

What kind of things influence schizophrenia prognosis?

A

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

202
Q

What are the different subtypes of schizoaffective disorder, and how do they differ?

A

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

203
Q

How long do psychotic episodes need to last for a diagnosis of schizoaffective disorder?

A

> = 2 weeks

204
Q

What are the diagnostic requirements for schizoaffective disorder?

A

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

205
Q

How should schizoaffective disorder be treated?

A

As per schizophrenia, and if the affective component is not being controlled add a mood stabiliser

206
Q

How quickly must psychosis resolve in order for it to be classified as an acute episode?

A

Within 3 months - and aim is to keep symptoms to <3m duration as psychosis is toxic to the brain

207
Q

How should acute psychosis be managed?

A

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

208
Q

What is delusional disorder, according to the ICD-10?

A

Persistent/ life-long delusions with no/few hallucinations: cannot inclue schizophrenic symptoms/ evidence of organic or brain disease/ clear auditory hallucinations

209
Q

How does onset affect prognosis in psychosis?

A

Rapid onset is associated with a better prognosis

210
Q

How should delusional disorder be managed?

A

There’s poor evidence for biologicals in this disorder - may use a BDZ for anxiety
Psychosocial - lots of psychoeducation, and social skills training

211
Q

Recall the important elements of the history in anxiety disorders

A 
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
212
Q

If the history reveals episodic anxiety, which 3 differentials should be considered?

A

Phobia, OCD, PTSD

213
Q

What type of psychological therapy is best for phobias?

A

Exposure therapy

214
Q

What type fo psychological therapy is best for OCD?

A

CBT

215
Q

Which anxiety disorders can be treated with medication, and which medication is best?

A

All of them - with SSRIs - most often sertraline

216
Q

What is the prognosis for anxiety generally?

A

Rule of 1/3s - 1/3 recover fully, 1/3 improve partially, 1/3 fare poorly

217
Q

How is GAD defined in the DSM-V?

A

At least 6 months of excessive, difficult to control worry and everyday issues that causes distress/ impairment

218
Q

Recall the possible symptoms of GAD

A 
Restlessness
Irritability
Fatiguability
Muscle tension
Sleep disturbance
Poor concentration
219
Q

How many symptoms need to be present most of the time for a GAD diagnosis?

A

3

220
Q

What questionnaire is useful in diagnosis of GAD?

A

GAD-7

Beck’s anxiety inventory/ HADS can also be used

221
Q

Recall the stepwise management for GAD

A
  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
222
Q

Which treatments should not be used in phobias?

A
  1. BDZs (high risk of dependence)

2. Antidepressants - specific phobias don’t respond well

223
Q

What is agarophobia?

A

Fear of leaving home/ entering shops/ crowds/ public places etc

224
Q

Into which 2 classifications is agarophobia classified?

A

As either with or without a panic disorder

225
Q

How is agarophobia managed?

A
  1. Education, reassurance and self-help
  2. Exposure Response Prevention
  3. CBT
226
Q

What is social phobia?

A

The fear of scrutiny of other people leading to avoidance of social situations

227
Q

How can social phobia and agarophobia be differentiated?

A

In social phobia they will tolerate anonymous crowds but smaller groups will spike anxiety

228
Q

How can specific phobias managed?

A

Education/ self-help/ Exposure Response Prevention

BDZs can be given short term

229
Q

What is panic disorder?

A

Recurrent attacks of severe anxiety that are not restricted to any particular circumstances and are therefore unpredictable

230
Q

What is the maximum duration of a panic attack?

A

30 mins

231
Q

How is panic disorder managed?

A

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

232
Q

What is OCD?

A

Disorder that may have recurrent obsessional thoughts or compulsive acts

233
Q

How long do OCD behaviours need to persist for OCD to be diagnosed?

A

> /= 2 consecutive weeks - must be a source of stress that interferes with ADLs

234
Q

Describe how obsessions are defined

A 
SUTURE
Must be: 
- Self-recognised as a product of own mind
- Unpleasantly repetitive
- Themed
- Unpleasurable to think about
- Resisted unsuccessfully at least once
- Egodystonic
235
Q

Describe how compulsions are defined

A

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

236
Q

Describe the gender balance of OCD prevalence?

A

Only anxiety disorder to affect men more than women

237
Q

Which part of the brain can be implicated in OCD?

A

Basal ganglia

238
Q

What is the rating scale that should be used for OCD?

A

Yale-Brown OCD scale

239
Q

Recall some examples of good questions to ask in an OCD history

A

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?

240
Q

How should OCD with mild functional impairment be managed?

A

CBT with Exposure Response Prevention

241
Q

How should OCD with moderate functional impairment be managed?

A

Intensive CBT with ERP or SSRI

242
Q

Recall the start doses of fluoxetine for:

  1. Depression
  2. Anxiety
  3. OCD
  4. Bulimia nervosa
A

Depression, OCD: 20mg
Anxiety: 40mg
Bulimia nervosa: 60mg/ 80mg

243
Q

Recall the 4 phases of cognitive therapy for OCD

A
  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)
244
Q

Define Acute Stress Disorder

A

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

245
Q

What are the key features of adjustment disorder?

A

Initial daze, constriction of conscious field, narrowing of attention, inability to comprehend stimuli, disorientation

246
Q

How should adjustment disorder be managed?

A

Support and reasurance, may give BDZs for short-term distress

247
Q

What may increase the risk of progression to PTSD from adjustment disorder?

A

Formal, immediate, psychological ‘debriefing’

248
Q

How long can adjustment disorder last?

A

No longer than 6 months

249
Q

Describe the presentation of adjustment disorder

A

Symptoms of anxiety and depression, without biological symptoms of depression

250
Q

What would make a grief reaction abnormal/ prolonged?

A

Delayed onset, increasing intensity of symptoms, suicidal idealisation, hallucinatory experiences

251
Q

For how long do symptoms need to persist in order to make a diagnosis of PTSD?

A

1 month

252
Q

What are the key signs and symptoms of PTSD?

A
  1. Re-experiencing
  2. Avoidance of triggers
  3. Hyperarousal
253
Q

Which questionnaire should be used in suspected PTSD?

A

Trauma screening questionnaire

254
Q

How should PTSD be managed?

A

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)

255
Q

What mnemonic can be used for investigating substance misuse in the history?

A 
TRAP: 
T = type
R = route
A = amount
P = pattern
256
Q

Recall the features of dependency

A 
Tolerance
Craving
Withdrawal
Difficulty controlling
Continuing despite negative consequences
Primacy (neglecting other interests) 
(reinstatemnt)
(narrowing of repetoire)
257
Q

What is the recommended maximum alcohol intake per week?

A

<14 U (both men and women)

258
Q

How many units EtOH per week are associated with hazardous and harmful drinking?

A 
Hazardous = 15-35 units per week
Harmful = > 35 units/ week
259
Q

What type of hallucinations may occur in delirium tremens?

A

Liliputian (seeing little people)

260
Q

What type of seizure might present in alcohol withdrawl syndrome?

A

Grand-mal

261
Q

What is a useful initial questionnaire for alcohol dependence investigation, and what are the questions?

A

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)?

262
Q

What are some useful rating scales of alcohol-dependence?

A

1st line = AUDIT (alcohol use disorders identification test) - 0-7 = low risk
2nd line = SADQ (severity and dependence questionnaire)

263
Q

What alcohol screening tool is used in AandE?

A

FAST (fast alcohol screening test)

264
Q

What is the triad of symptoms in Wernicke’s encephalopathy?

A

Ataxia, opthalmoplegia, confusion

265
Q

How many units a day does someone need to drink in order to be admitted as an inpatient for withdrawal?

A

> 30 U per day

266
Q

What are the 1st line chronic treatments for alcohol withdrawal?

A

Acamprosate/ naltrexone

267
Q

What drug should be administered in the case of an alcohol withdrawl seizure?

A

IV lorazepam

268
Q

What drugs should be administered in delirium tremens?

A

Oral lorazepam and IV thiamine/ pabrinex

269
Q

What is the mechanism of action of acamprosate?

A

Enhances GABA transmission to remove craving for alcohol

270
Q

What psychological therapy is appropriate in alcohol detox?

A

Motivational interviewing

271
Q

What structure is damaged by B12 deficiency?

A

Mammillary damage

272
Q

What are the symptoms of Wernicke’s encephalopathy?

A

Ataxia, opthalmoplegia, acute confusion (TRIAD)

273
Q

What are the symptoms of Korsakoff’s psychosis?

A

Anterograde amnesia, confabulation, peripheral neuropathy, cerebellar degenration

274
Q

From what plant are opiates derived?

A

Papaver somniferum

275
Q

What is the most serious infection that you can get from injecting heroin?

A

Hepatitis C

276
Q

Recall 4 local complications of heroin injection

A

Abscess, cellulitis, DVT, emboli (AbCDE) + pseudoaneurysm

277
Q

Recall 4 systemic complications of heroin injection?

A

Septicaemia, infective endocarditis, blood-borne infections, risk of OD

278
Q

Recall the symptoms of heroin intoxication

A

Euphoria and ‘warmth’
OD: pinpoint pupils and low RR
Low-dose side effects: constipation, anorexia, decreased libido

279
Q

How should opiate OD be treated?

A

Naxolone

280
Q

What are the symptoms of opiate withdrawal?

A

Craving, insomnia, agitation, flu-like symptoms, the ‘runs’ (D+V, lacrimation, rhinorrhoea), goose flesh, mydriasis

281
Q

How long after injection of heroin do withdrawal symptoms begin?

A

6 hours after injection

282
Q

How long do opiate withdrawal symptoms last?

A

5-7 days

283
Q

How long do opiates stay in the urine?

A

2 days

284
Q

How should opiate use be managed?

A
  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
285
Q

What are the two stages of Opiate Substitution Therapy?

A

Stabilisation and detoxification

286
Q

How long does Opiate Substitution Therapy last as an outpatient?

A

12 weeks minimum

287
Q

What are the first line treatments for Opiate Substitution Therapy?

A

Methadone or buprenorphine - and offer naxolone to take home with them and training on when/ how to use it

288
Q

What is the second line drug for Opiate Substitution Therapy, and when would it be indicated?

A

Lofexidine (alpha-2-agonist)

Indications = rapid detox, mild dependence, preference

289
Q

What is the minimum duration of follow-up care following opiate detoxification?

A

6 months

290
Q

For how long following last use is cannabis present in urine?

A

4 weeks

291
Q

Recall some chronic complications of cannabis use

A

Dysthymia, anxiety/ depressive illness, amotivational syndrome

292
Q

Recall 4 types of hallucinogenic drug

A

LSD, phencyclidine, ketamine, magic mushrooms

293
Q

How long can an LSD trip last?

A

12 hours

294
Q

What is a street name for phencyclidine?

A

Angel dust

295
Q

What are the symptoms of phencyclidine use?

A

Violent outbursts and ongoing psychosis

296
Q

Recall the symptoms of ketamine use in smaller and larger doses

A 
Smaller = dissociation
Larger = hallucinations and synaesthesia
297
Q

Recall the symptoms of magic mushroom use in smaller and larger doses

A 
Small = euphoria
Large = hallucinations
298
Q

What can be used to treat hallucinogen withdrawal short term?

A

BDZs

299
Q

What stimulant is most often used in East African communities?

A

Khat/ quat/ chat

300
Q

Which recreational stimulant drug class may cause dependence?

A

Amphetamines

301
Q

Recall some acute side effects of cocaine use

A

Arrhythmia, intense anxiety, HTN

302
Q

Recall some chronic side effects of cocaine use

A

Nasal septum necrosis, foetal damage, panic and anxiety, delusions, psychosis

303
Q

How can ecstasy cause death?

A

Via dehydration and hyperthermia

304
Q

Recall the 2 phases of cocaine withdrawal

A
  1. Crash phase - depression, agitation, irritability

2. Withdrawal - poor concentration, insomnia, slowed movements

305
Q

How long does cocaine remain in urine?

A

5-7 days

306
Q

What is the most significant risk of BDZ use?

A

Dependence

307
Q

What is the result of BDZ overdose?

A

Respiratory depression

308
Q

How should BDZ overdose be treated?

A

IV flumenazil

309
Q

What are the 2 options for BDZ withdrawal management?

A
  1. Slow-dose reduction

2. Switch to diazepam equivalent dose and then slow-dose reduction

310
Q

What is the most common side effect of BDZ withdrawal?

A

Anxiety

311
Q

At what rate should BDZ dose be reduced?

A

1/8th dose every 2 weeks

312
Q

What are the 3 medical options for smoking cessation?

A

Nicotine replacement therapy, varenicline, bupropion

313
Q

What is the mechanism of action of Varenicline and Bupropion?

A 
Varenicline = partial nicotine receptor agonist
Bupropion = selective DA and NA reuptake inhibitor (weak)
314
Q

How long before the quit date should Bupropion and Varencline be started?

A

7-14 days

315
Q

Recall some contraindications for varenicline

A

<18 y/o, renal disease

316
Q

Recall some contraindications for bupropion

A

<18 y/o, seizures, CNS disorder, eating disorder, BPAD, cirrhosis

317
Q

Recall the 3 Ps necessary to diagnose personality disorder?

A

Persistent, pervasive and pathological

318
Q

Recall the 3 broad clusters of personality disorders

A

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

319
Q

What criteria must be met to diagnose a personality disorder?

A

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)

320
Q

What is the supposed prevalence of personality disorder?

A

10%

321
Q

What are the differences between schizotypal and schizoid personality disorders?

A

Schizotypal: some positive schizophrenia symptoms = eccentricity, paranoia, social withdrawal and inappropriate affect
Schizoid: just negative schizophrenia symptoms

322
Q

Recall the features of paranoid personality disorder

A 
SUSPECT
S - sensitive
U - unforgiving
S - suspicious
P - possessive/ jealous
E - excessive self-importance
C - conspiracy theories
T - tenacious sense of rights
323
Q

Recall the features of schizoid personality disorder

A

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
324
Q

Recall the features of histrionic personality disorder

A 
ACTORS
A - attention-seeking
C - concerned with appearance
T - theatrical
O - open to suggestive
R - racy/ suggestive
S - shallow affect
325
Q

Recall the features of emotionally unstable personality disorder

A 
AEIOU
A - affective instability
E - explosive behaviour
I - impulsive
O - outbursts of anger
U - Unable to plan/ consider consequences
326
Q

Recall the features of dissocial personality disorder

A 
FIGHTS
F - Forms, but cannot maintain relationships
I - irresponsible
G - guiltless
H - heartless
T - temper easily lost
S - someone else's fault
327
Q

Recall the features of anankastic personality disorder

A 
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
328
Q

Recall the features of anxious/ avoidant personality disorder

A 
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
329
Q

Recall the features of dependent personality disorder

A 
SUFFER
S - subordinate
U - undemanding
F - fears abandonement
F - feels helpless when alone
E - encourages others to make decisions 
R - reassurance needed
330
Q

What is ‘splitting’ in personality disorders?

A

An immature response where a person cannot reconcile the good and bad in someone and only views them as ‘good’ or ‘bad’

331
Q

In which conditions may splitting be seen?

A

EUPD/ BPD

332
Q

What does ‘dissociation’ describe in personality disoder?

A

An immature ego defence where one assumes a differerent identity to deal with a situation

333
Q

What is sublimation?

A

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)

334
Q

What is a ‘reaction formation’ in personality disorder?

A

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)

335
Q

What is ‘identification’ in personality disorder?

A

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)

336
Q

What is ‘displacement’ in personality disorder?

A

Defence mechanism whereby someone takes out their emotions on a neutral person

337
Q

What is ‘projection’ in personality disorder?

A

Where a person assumes an innocent or neutral character is guilty for the patient’s actions

338
Q

Which medications might be used in cluster A personality disorders?

A

None

339
Q

Which medications might be used in cluster B personality disorders?

A

antipsychotics, antidepressants and lithium

340
Q

Which medications might be used in cluster C personality disorders?

A

Lithium

341
Q

In which personality disorders is dialetical behaviour therapy particularly useful?

A

EUPD/BPD

342
Q

What are the 2 concepts introduced by DBT?

A

Validation (your emotions are acceptable)

Dialectics (things in life are rarely black and white)

343
Q

Which eating disorder is most genetically heritable?

A

Anorexia nervosa

344
Q

How can you test for proximal myopathy?

A

Squat test

345
Q

What is the expetced T4 thyroid measurement in patients with an eating disorder?

A

Low

346
Q

What ECG abnormality may be present in bulimia nervosa?

A

Long QT

347
Q

What are some indications for immediate admission in high risk patients with eating disorders?

A 
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
348
Q

What is required for anorexia nervosa diagnosis in the ICD-10?

A
  1. BMI < 17.5
  2. Deliberate weight loss
  3. “Fear of the fat”
349
Q

How are anorexia nervosa and bulimia nervosa distinguished clinically?

A

AN = underweight, BN = normal/ increased weight

350
Q

What is Russel’s sign?

A

Callous/ cut knuckles from self-induced vomiting

351
Q

How is anorexia nervosa managed?

A

NO WATCHFUL WAITING - refer immediately

352
Q

What are the AandE guidelines used for patients with anorexia nervosa?

A

MARISPAN (Management of Really Sick Patients with AN)

353
Q

At what BMI should someone be referred to Community Eating Disorder Services urgently?

A

<15

354
Q

Alongside a referral, in what 3 ways should anorexia nervosa be managed by the GP?

A
  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
355
Q

What are the first line options for treatment of anorexia nervosa in secondary care?

A

CBT-ED
MANTRA (Maudsley AN Treatment in Adults)
SSCM (Specialist Supportive Clinical Management)

356
Q

What is the duration of CBT-ED?

A

40 weekly sessions

357
Q

What is the focus of MANTRA therapy for anorexia nervosa?

A

Focusing on the cause of the anorexia nervosa

358
Q

Describe SSCM treatment for anorexia nervosa

A

Explore problems of anorexia, educate on nutrition and eating habits, explore a future beyond anorexia

359
Q

What is the target weight gain range for AN patients?

A

0.5-1.0kg/ week

360
Q

When should pharmacological managemrnt be used in AN?

A

If physical symptoms, rapid weight loss or BMI <13.5

361
Q

What is the appropriate drug for pharmacological treatment of AN?

A

Fluoxetine

362
Q

What are the first and second line treatments for children with AN?

A

1st line = family therapy

2nd line = ED-CBT

363
Q

What is the main defining feature of the Refeeding Syndrome?

A

Low phosphate

364
Q

What is the aetiology of the refeeding syndrome?

A

Intracellular shift in (already low) ions due to insulin release upon refeeding

365
Q

Which electrolytes are low in the refeeding syndrome?

A

Low K+, low phosphate, low magnesium

366
Q

What screening questionnaire can be used to screen for anorexia as well as bulimia?

A

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?

367
Q

What are the criteria for diagnosing BN?

A

Must have all 3 of:

  1. Binging/ irresistable craving for food
  2. Purging behaviours
  3. Psychopathology (feeling loss of control. Morbid dread of fatness)
368
Q

What is BED?

A

Binge eating disorder - most common ED, does not include purging pathology

369
Q

How should bulimia nervosa be managed?

A

Like anorexia, refer immediately and screen for immediate admission (most are managed in the community)

370
Q

How should bulimia nervosa be managed by the GP alongside referral?

A
  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)
371
Q

Differentiate between dissociative disorder and somatisisation disorder

A

DD = disorders of physical functions under voluntary control and loss of sensation

SD = disorders involving pain or autonomically-controlled sensations

372
Q

What is dissociative fugue?

A

Dissociative amnesia + purposeful travel beyond everyday range

373
Q

What is a dissociative stupor?

A

Lack of voluntary movement/ normal responses to external stimuli

374
Q

What are trance and posession disorders?

A

Temporary loss of personal identity and full sense of awareness of surroundings

375
Q

What part of the body is affected by dissociatve motor disorders?

A

Limbs

376
Q

How can dissociative convulsions be distinguished from an epileptic seizure?

A

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

377
Q

How can dissociative anaesthesia be distinguished from organic anaesthesia?

A

Areas of anaesthesia do not follow normal dermatomal distribution

378
Q

How is somatisation defined?

A

Multiple, recurrent and frequently changing physical symptoms of 2 years duration without evidence of underlying organic cause

379
Q

Recall the 4 subtypes of somatisation disorder

A
  1. Undifferentiated somatoform disorder
  2. Hypochondrial disorder
  3. Somatoform autonomic dysfunction
  4. Persistent somatoform pain disorder
380
Q

What are the hallmark features of hypochondrial disorder?

A

Often cancer

Pre-occupation with a single problem

381
Q

What is somatoform autonomic dysfunction?

A

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)

382
Q

What is the age-limit for early-onset dementia?

A

65 years old

383
Q

What are the 2 most useful screening questionnaires for dementia?

A

AMTS, GPCOG

384
Q

What AMTS score suggests cognitive impairment?

A

<7

385
Q

What is the most detailed assesment of possible dementia?

A

Addenbrooke’s (ACE-R) - 100 questions

386
Q

How many questions are in the MMSE?

A

30

387
Q

What would be the appearance on MRI of a brain affected by Alzheimer’s?

A

Grey matter atrophy, wide ventricles and sulci, temporal lobe atrophy

388
Q

What biomarker can be used to identify Lewy Body dementia?

A

123|-FP-CIP SPECT

389
Q

What are the 3 theories of Alzheimer’s aetiology?

A

Amyloid (beta secretase replaces alpha secretase –> toxic aggregates that form A-Beta protein)
Tau (hyperphosphorylated tau is insoluble)
Inflammation (to do with CNS macrophages)

390
Q

Which region of the brain is the first to be affected by Alzheimer’s disease?

A

hippocampus

391
Q

Recall 4 genetic risk factors for Alzheimer’s

A

Presenelin 1
Presenelin 2
Beta-amloid precursor protein gene
Co-existent Downs syndrome

392
Q

What are the 4 key elements of pathophysiology in Alzheimer’s?

A

Atrophy from neuronal loss
Plaque formation
Neurofibrilliary tangles
Cholinergic loss

393
Q

How does Alzheimer’s characteristically present?

A

The 4 ‘A’s:

  • Amnesia
  • Aphasia
  • Agnosia
  • Apraxia
394
Q

If a short-term antipsychotic is required in Alzheimer’s disease, which is most appropriate?

A

Risperidone

395
Q

Recall the options for medical management of Alzheimer’s

A 
1st line (mild-moderate) = anticholineesterases: donezepil/ galantamine/ rivastigmine 
2nd line (moderate - severe) = memantine - a NMDA (glu) partial receptor agonist
396
Q

What is the first line option for psychological management of Alzheimer’s?

A

Structural group cognitive stimulation

397
Q

What checks should be done before anti-cholineesterase prescription?

A

1st = ECG
Check medications: absolute contraindications are anticholinergics, beta-blockers, NSAIDs and muscle-relaxants
Relative contra-indications = asthma, COPD, GI disease, braadycardia, AV block

398
Q

What is the common presentation of vascular dementia?

A

Step-wise decline that starts with emotional/ personality changes (including labile emotion) and deteriorates to produce cognitive deficit

399
Q

How should vascular dementia be managed?

A 
Manage RFs (daily aspirin, dietary advice, stop smoking etc) 
Same psychological treatment as alzheimer's dementia
400
Q

What are Lewy bodies composed of?

A

Alpha synuclein with ubiquitin

401
Q

Describe the distribution of Lewy bodies in Lewy Body Dementia vs Parkinsons disease

A

LBD = brainstem, cingulate gyrus and neocortex

In PD = just brainstem

402
Q

Describe the classical presentation of Lewy body dementia

A

Fluctuating confusion with marked variations in alertness levels

403
Q

What confusing symptoms may be seen in Lewy body dementia?

A

Lilliputian hallucinations (like delirium)
Parkinsonianism
Frequent falls

404
Q

What is an important medication NOT to offer in Lewy body dementia?

A

Antipsychotics - they increase risk of cerebrovasvular disease

405
Q

What medical management can be used in Lewy body dementia?

A

Same as Alzheimers disease - anti-cholineesterases

406
Q

What is another name for frontotemporal dementia?

A

Pick’s disease

407
Q

What is especially unusual about frontotemporal dementia?

A

Early onset (usually 40 to 60 years)

408
Q

Recall the signs and symptoms of frontotemporal dementia

A
  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)
409
Q

What two investigations are most useful in frontotemporal dementia?

A

FDG-PET (fluorodeoxyglucose), MRI (to see frontal lobe shrinkage)

410
Q

What is the prognosis for frontotemporal dementia?

A

Death in 5-10 years

411
Q

What is the inheritance pattern of Huntingdon’s?

A

Autosomal dominant so 50% chance of children inheriting

412
Q

When in the life-course is the onset of Huntingdon’s?

A

30-50 years old

413
Q

What is the general clinical picture of Huntingdon’s?

A

Clumsy, speech difficulties

414
Q

Recall some signs and symptoms of Huntingdon’s

A

Movement: chorea, slurred speech, stumbing/ clumsiness
Cognitive: difficulty organising, learning, being flexible
Psychiatric - depression, irritability, suicide in 9%

415
Q

What are chorea?

A

Involuntary jerking movement that tend to flow from one area to another

416
Q

What is the model for formulation in CAMHS?

A

Biological, psychological and social for the 4 ‘P’s: predisposing, precipitating, perpetuating and protecting

417
Q

What are the ICD-10 criteria for diagnosis of ADHD?

A

Impaired attention and overactivity, present prior to 6 years of age, of long duration, and present in
two or more settings

418
Q

What rating scale can be used to asses ADHD?

A

Conner’s Comprehensive Behaviour Rating Scale (age 6-18)

419
Q

How should ADHD be managed?

A

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
420
Q

What are some side effects of methylphenidate?

A

Abdo pain, nausea, dyspepsia

421
Q

Recall some important things to monitor whilst giving ADHD medication

A
  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)
422
Q

What % of children with ADHD have it as an adult?

A

15%

423
Q

What medication during pregnancy can increase risk of Autism spectrum disorder?

A

Sodium valporate

424
Q

Recall 4 important associations of ASD

A

Fragile X syndrome
Tuberous sclerosis
Neurofibromatosis
Di-George

425
Q

What is the difference between Asperger’s and Autism?

A

Asperger’s has no delay in language/ cognitive development

426
Q

What is Rett syndrome?

A

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

427
Q

What is the most common form of ASD?

A

Pervasive Developmental Disorder Not Otherwise Specified (PPD-NOS)

428
Q

In what 3 spheres of life are there abnormalities in Autistic spectrum disorder?

A

Social interaction
Communication
Patterns of behaviour/ interests/ activities

429
Q

What are the typical motor mannerisms of children with ASD?

A

Finger flapping and repetitive whole-body movements

430
Q

Recall a simpler easy diagnostic triad for ASD

A

Deficits in:

  1. Verbal and non-verbal communication
  2. Reciprocal social interaction
  3. Restrictive or repetitive behaviours/ interests
431
Q

What is one hallmark symptom of Autism spectrum disorder?

A

Echolalia

432
Q

Recall the 2 gold standard diagnostic tools for ASD

A
  1. ADI-R (autism diagnostic inventory - revised)

2. ADOS (Autism Diagnostic Observatory Schedule)

433
Q

Describe the management of Autistic spectrum disorder

A

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

434
Q

Define conduct disorder

A

Repetitive and persistent pattern of antisocial behaviour which violates basic rights of others that are not in line with age-appropriate social norms

435
Q

In which age group can oppositional defiant disorder exist?

A

<10 years old

436
Q

For how long must symptoms persist for a diagnosis of conduct disorder?

A

6 months

437
Q

How should conduct disorder be managed?

A

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

438
Q

By what 3 criteria is learning difficulty defined?

A

IQ < 70, impaired social/ adaptive functionning, onset in childhood

439
Q

At what IQ level is the cause of LD considered to be always organic?

A

IQ <50

440
Q

What is the most prevalent physical symptom of learning difficulties?

A

Poor sleep/ wake cycle

441
Q

What scale is used to assess intellectual impairment?

A

WAIS II

442
Q

What medications might be useful in learning difficulties?

A

Melatonin for sleep

443
Q

Which law protects reasonable adjustment?

A

Disability act 1995

444
Q

Which MMSE scores indicate no impairment/ mild impairment/ severe impairment?

A

24-30 - No cognitive impairment
18-23 - Mild cognitive impairment
0-17- Severe cognitive impairment

445
Q

In anorexia nervosa, which things will be high on a blood test?

A

G’s and C’s raised: growth hormone, glucose, salivary Glands, cortisol, cholesterol, carotinaemia

446
Q

How long after a change in lithium dose should the levels be taken?

A

7 days later and 12 hours following last dose

447
Q

What electrolyte abnormality is associated with SSRIs?

A

Hyponatraemia

448
Q

What is the anti-depressant of choice following a myocardial infarction?

A

Sertralline

449
Q

What is acute dystonia?

A

Sustained muscle contraction (eg oculogyric crisis, torticollis)

450
Q

How can acute dystonia be managed?

A

Procyclidine

451
Q

What is acute dystonia a side effect of?

A

Antipsychotics (typical and atypical alike)

452
Q

What is the most common endocrine disorder developing as a result of chronic lithium toxicity?

A

Hypothyroidism

453
Q

What is the main risk of using paroxetine in pregnancy?

A

Congenital malformations

454
Q

Which antipsychotic reduces the seizure threshold?

A

Clozapine

455
Q

What drug can be used to treat tardive dyskinesia?

A

Tetrabenazine

456
Q

What is the main risk of SSRI use in the third trimester of pregnancy?

A

Persistent pulmonary hypertension of the newborn

457
Q

What are the metabolic side effects of antipsychotics?

A

Hyperlipidaemia

Diabetes mellitus

458
Q

How should antidepressant medication be managed prior to ECT treatment?

A

The dose should be reduced but not stopped

459
Q

What is the most prominent symptom of SSRI-discontinuation syndrome?

A

Diarrhoea

460
Q

What type of incontinence can be caused by TCAs?

A

Overflow incontinence

461
Q

Which psychiatric drug can cause hyperparathyroidism?

A

Lithium

462
Q

Which antipsychotics can be given as a long-acting depot injection, and which of these are typical vs atypical antipsychotics?

A

Typicals: Zuclopenthixol is the main one (Clopixol), also flupentixol
Atypicals: Risperidone

463
Q

How can you differentiate the NMS with serotonin syndrome based on the neuromuscular abnormalities they produce?

A

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)

464
Q

How do bromocriptine and dantrolene work to treat the NMS?

A

Bromocriptine reverses dopamine blockade
Dantrolene reduces muscle spasm
ECT

THURSDAY Year 5 Specialties Ludley's (COPY) (10 decks)

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