ICSM Year 5 Psychiatry Flashcards
1
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
2
Q
What is a reference delusion?
A
Patient believes unsuspicious thing has reference to them, eg. TV programme dialogue refers to them
3
Q
Recall the 3 types of thought disorder
A
Insertion, withdrawal and broadcasting
4
Q
What is Cotard’s syndrome?
A
Nihilistic delusion in which pt believes they are rotting/ dead - can occur in severe depression
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
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
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
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)
9
Q
Who may apply for section 2/3 detainment under the MHA?
A
AMHP (approved mental health professional) or NR (nearest relative)
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
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)
12
Q
What qualification is required for someone to detain a patient under Section 4 of the MHA?
A
Must be a psychiatrist
13
Q
What does section 5(4) of the MHA allow?
A
Detention of an inpatient by a nurse
14
Q
What is the maximum duration of detention under section 5(4) of the MHA?
A
6 hours (detention by nurse)
15
Q
What does section 17 of the MHA allow?
A
Allows leave from a current section, but is not permanent discharge
16
Q
What does section 35 of the MHA permit?
A
Assessment of a patient accused of committing a crime
17
Q
How long does assesment last under section 35?
A
28 days
18
Q
What are the appeal requirements to section 35 of the MHA?
A
You can’t appeal
19
Q
What does section 37 of the MHA permit?
A
Treatment of a convicted criminal - otherwise like section 3
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)
21
Q
What section of the MHA is applied for by the Crown Court?
A
Section 41 - a restriction order
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
23
Q
What is a community treatment order?
A
Discharge from a previous section providing certain conditions are met - requires renewal every 6 months
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
25
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
26
What does DoLS stand for?
Deprivation of Liberty Safeguards (within MCA 2005) - which can be within a carehome or hospital
27
What is the mechanism of action of most antipsychotic drugs vs clozapine?
Dopamine receptor antagonists - most block D2 but Clozapine blocks D1 and D4
28
Recall some common side effects of anti-psychotics
Extrapyramidal - dystonia/ akathisia/ parkinsonisms/ tardive dyskinesias (more common in typicals)
Hyperprolactinaemia (galacorrhoea, amenorrhoea, gynaecomastia)
Weight gain
29
Why do atypical antipsychotic drugs have fewer side effects than typicals?
More selective (just antagonise D2 and 5-HT2 receptors)
30
What class of drug is the first line treatment in schizophrenia?
Atypical antipsychotic
31
What class of drug is the first line treatment in relapsed schizophrenia?
Typical antipsychotic
32
In the elderly, what extra risk do antipsychotic drugs carry?
Increased risk of stroke and VTE
33
Describe how the dosage of clozapine is controlled
Start low and titrate up slowly, if >48 hours missed medication, need to start again
34
Recall one caution of using clozapine
If patient stops smoking suddenly, the clozapine levels will suddenly go up
35
Recall 2 examples of typical antipsychotics
Haloperidol, chlorpromazine
36
Recall 4 examples of atypical antipsychotics
Clozapine, risperidone, apiprazole, olanzapine, quetiapine
37
Recall one significant side effect to remember of clozapine
Agranulocytosis (1%)
38
Recall one drug interaction of clozapine
Lithium
39
What is neuroleptic malignant syndrome?
A major side effect of antipsychotics characterised by fever, altered mental status, muscle rigidity, and autonomic dysfunction
40
What is akathisia?
An unpleasant subjective feeling of restlessness
41
What is tardive dyskinesia?
Rhythmic involuntary movements of the mouth, face, limbs and trunk
42
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
43
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
44
Recall the symptoms of suddenly stopping antidepressant medication
```
FIRM STOP
Flu-like symptoms
Insomnia
Restlesness
Mood swings
```
Sweating
Tummy problems
Off-balance (ataxia)
Paraesthesia
45
Recall 4 examples of SSRIs
For Sadness, Panic, Compulsion:
| Fluoxetine, sertraline, paroxetine, Citalopram
46
For approx how long do SSRIs make someone feel worse before they feel better?
1-2 weeks
47
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
48
Recall one important interaction of SSRIs
Triptans - interaction can cause serotonin syndrome - so ask about migraines
49
Recall one important side effect of citalopram
QT prolongation
50
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)
51
Recall the main side effects of all SSRIs
```
The 5 'S's:
Suicidal idealisation
Stomach (weight gain, DNV)
Sexual dysfunction
Sleep (insomnia)
Serotonin syndrome
```
52
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
53
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
54
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
55
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
56
What does SNRI stand for?
Serotonin-noradrenaline reuptake inhibitor
57
What is the main side effect of SNRIs?
Headache
58
Recall 2 examples of SNRIs
Venlaxafine, duloxetine
59
Describe the side effects of SNRIs
Same '5S' as SSRIs but also constipation, HTN + raised cholesterol
60
What is the mechanism of action of TCAs?
Block serotonin and NA reuptake
61
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
62
Why are TCAs not given if there is risk of suicide?
Can be fatal in OD
63
What is one key contraindication for TCAs?
If patient is also taking a monoamine oxidase inhibitor
64
Recall the side effects of TCAs
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
65
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"
66
Give 2 examples of TCAs
Amitriptyline, clomipramine
67
What type of antidepressant is mirtazapine?
noradrenergic and specific serotonin antidepressant (NaSsA)
68
What is the most common side effect of mirtazapine?
Weight gain
69
When is mirtazapine indicated?
Triad of depression + insomnia + loss of appetite
70
Give 2 examples of MAOI antidepressants
Phenelzine, selegiline
71
What does MAOI stand for?
MonoAmine Oxidase Inhibitor
72
What is the main risk of MAOI use?
Hypertensive cheese reaction
73
What type of antidepressant is moclobemide?
Reversible Inhibitor of Monoamine oxidase A (RIMA)
74
What is the max length of prescription for a BDZ drug?
2-4 weeks
75
What is the mechanism of action of BDZs and BARBs?
Enhance GABA transmission at GABA-A receptor
76
How does the mechanism of action of BDZs and BARBs differ?
BDZ increases duration of receptor opening, BARB increases frequency of opening
77
Why are barbiturates more dangerous than BDZs?
Less selective so more excitatory transmission
78
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
79
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
80
Give 2 examples of short-acting BDZs and recall their main clinical use
Teazepam, oxazepam - used as sedatives
81
What is a Z drug used to treat?
Treats insomnia (similar to a BDZ)
82
Give an example of a Z drug
Zopiclone
83
When should Z drugs be used?
Only when insomnia is severe and disabling
84
What is a key side effect of zopiclone?
Increased risk of falls
85
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
86
What is the antidote to zopiclone, and its mechanism of action?
Flumenazil (BDZ antagonist)
87
Why should zopiclone not be used in pregnancy?
Can cause a cleft lip
88
What are stimulants used to treat?
ADHD and narcolepsy
89
Give 2 examples of stimulant drugs used to treat ADHD
Methylphenidate (Ritalin)
| Dexaphetamine
90
What is the mechanism of action of stimulant drugs used in ADHD?
Potentiate the effect of monoamine neurotransmitters (DA, NA, 5HT)
91
Recall some side effects of stimulant drug use
Cardiac pathology, drug-induced psychosis, appetite suppression, "risky" behaviour, insomnia, impulsivity
92
What are mood stabilising drugs used to treat?
BPAD, schizoaffective disorder
93
What are the 4 main mood stabilising drugs?
Lithium (1st line), valporate (2nd line), carbamazapine, lamotrigine
94
Recall 4 key side effects of lithium
Mild tremor, hypothyroidism, eyebrow hair loss, nephrogenic DI
95
How does a lithium OD present?
```
Tremor
Ataxia
GI disturbance/ urinary symptoms
Seizures
AKI
```
96
What regular monitoring should be done in lithium prescription?
Every 3 months: lithium levels, every 6 months: UandEs and TFTs
97
Why should lithium not be used in pregnancy?
Causes Ebstein's abnormality (heart defect)
98
Recall 2 key side effects of valporate
Hair loss + weight gain
99
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
100
What is the main risk of using carbamazipine in pregnancy?
Spina bifida
101
What is the key side effect of lamotrigene use?
Severe skin rash - SJS
102
What is the most likely drug to cause the neuroleptic malignant syndrome?
Haloperidol
103
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
104
In what time frame does the NMS develop?
4-11 days after starting any antipsychotic medication
105
What investigations should be done to identify NMS?
FBC (to show leucocytosis), UandEs (show high CK and AKI)
106
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
107
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)
108
What symptom is likely to present in the serotonin syndrome but not the NMS?
Diarrhoea and Vomiting
109
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
110
How does ECT work?
Induces a generalised tonic-clonic seizure under general anaesthetic
111
What are the indications for ECT?
ECT:
Euphoric (manic episodes)
Catatonia (not moving in an unusual position)
Tearful (severe depression that is life-threatening)
112
What is an absolute contraindication for ECT?
Raised intracranial pressure
113
What are the short term side effects of ECT?
Headaches and nausea, muscle aches, cardiac arrhythmia, retrograde amnesia (loss of memories before the ECT)
114
What is the main target of CBT?
So-called 'Negative Automatic Thoughts'
115
What is Beck's negative cognitive triad
Self-perpetuating triad of:
- Negative self-view
- Negative future view
- Negative world view
116
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")
117
Recall the name of 2 CBT methods used to tackle negative thought patterns
Longitudinal format/ hot-cross bun methods
118
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
119
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
120
What is the difference between psychoanalytics and psychodynamics?
```
Psychoanalytics = internal conflicts
Psychodynamics = interpersonal conflicts
```
121
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
122
Recall 4 protective factors against suicide
Married, lithium medication, faith, no substance abuse
123
What is the reversing agent for overdose on a BDZ?
Flumenazil
124
What is the reversing agent for overdose on a Z drug?
Flumenazil
125
What is the reversing agent for overdose on an opiate?
Naloxone
126
What is the reversing agent for overdose on paracetamol?
N-acetylcysteine
127
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
128
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
129
How is delirium diagnosed?
Confusion Assesment Method
130
How is delirium managed?
Modify risk factors, exclude diagnosed dementia, treat the causes
131
What is the medical management of delirium?
PO antipsychotics, AVOID anticholinergics
132
What is the prognosis for delirium?
37% die within 6 months, only 25% have a clinically important recovery in ADLs
133
What drug can be used IM to rapidly tranquilise if the individual refuses PO medications?
IM lorazepam
134
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?
135
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)
136
How long should be left to assess a patient's response to oral tranquilisation?
1 hour at least
137
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)
138
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
139
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
140
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
141
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)
142
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)
143
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
144
What are the 2 core symptoms of depression?
Low mood + anhedonia
145
What are the adjunct symtpoms of depression?
```
Fatigue
Insomnia
Concentration problems
Appetite change
Suicidal thoughts/ acts
Agitation/ slowing of movements
Guilt
```
146
Recall 3 medications that may cause depression
Steroids, COCP, propranalol
147
What is dysthymia?
Subthreshold depression (2-5 symptoms) of depression for at least 2 years
148
What is atypical depression?
Just somatic symtpoms (weight gain, hypersomnia)
149
What can improve the symptoms of anxiety-induced insomnia?
Mood is increased by increased sleep and eating
150
What is a depressive stupor?
Such extreme psychomotor retardation that the individual grinds to a halt
151
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)
152
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)
153
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)
154
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
155
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
156
What is the first line antidepressant medication?
SSRIs (sertraline, citalopram, fluoxetine, paroxetine)
157
When should a second line antidepressant be tried?
After trying 2 different SSRIs
158
What is the second line antidepressant medication?
SNRIs (venlaxafine, duloxetine)
159
Recall the stepped increase of dose of venlaxafine
37.5mg BD --> 75mg BD --> 75mg morning, 150mg evening
160
What is the indication for 3rd line antidepressant treatment?
If they are resistant to treatment, you can't augment treatment with further medication
161
What are the 3rd line treatment options for depression medication?
Antipsychotic (eg quetiapine), lithium, or other antidepressant eg mirtazapine
162
What is the ideal blood level of lithium?
0.6-1.0 (toxicity at >2.0)
163
In which scenario is mirtazapine most useful?
When symptoms of insomnia and appetite reduction are evident and debilitating
164
Describe the side effect profile of sertraline
Smallest side-effect profile, so a good one to give to people with comorbid IHD
165
What is the best antidepressant to give to children?
Fluoxetine
166
What is the most common use of paroxetine?
For major depressive episodes
167
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
168
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
169
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
170
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
171
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
172
What is hypomania?
>3 characteristics of mania lasting at least 4 days, no impairment of functioning, no delusions/ psychosis
173
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
174
What is rapid cycling BPAD?
More than 4 episodes per year
175
What is the best treatment for rapid cycling BPAD?
Sodium valporate - they respond well
176
How much is BPAD risk increased by a 1st degree relative having BPAD?
7 fold
177
What is the rating scale used to investigate BPAD?
Young mania rating scale
178
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
179
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
180
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
181
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
182
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
183
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
184
What is the use of psychological therapies in BPAD?
May improve compliance with medication long term
185
What is the prognosis for BPAD?
15% willl commit suicide, but lithium reduces this to same level as general population
186
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
187
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
188
What is wavy flexibility?
They will retain any shape you put them into!
189
What is the most common subtype of schizophrenia?
Paranoid schizophrenia
190
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
191
How does cannabis use increase risk of schizophrenia?
Val allele encoding COMT insead of Met allele in non-smokers
192
What rating scale is used to investigate schizophrenia?
Brief psychiatric rating scale
193
What type of prescription drug use may cause symptoms of schizophrenia?
Steroids
194
What is schizoaffective disorder?
Schizophrenic and affective symptoms develop together and are balanced
195
What is schizotypal disorder?
Eccentricity with abnormal thoughts
196
By what teams should schizophrenia be managed in an urgent emergency?
Crisis Resolution Team and Home Treatment Team
197
By which team should schizophrenia be managed when it is not urgent?
Early Intervention in Psychosis (EIP) team
198
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
199
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
200
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
201
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
202
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
203
How long do psychotic episodes need to last for a diagnosis of schizoaffective disorder?
>= 2 weeks
204
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
205
How should schizoaffective disorder be treated?
As per schizophrenia, and if the affective component is not being controlled add a mood stabiliser
206
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
207
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
208
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
209
How does onset affect prognosis in psychosis?
Rapid onset is associated with a better prognosis
210
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
211
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
```
212
If the history reveals episodic anxiety, which 3 differentials should be considered?
Phobia, OCD, PTSD
213
What type of psychological therapy is best for phobias?
Exposure therapy
214
What type fo psychological therapy is best for OCD?
CBT
215
Which anxiety disorders can be treated with medication, and which medication is best?
All of them - with SSRIs - most often sertraline
216
What is the prognosis for anxiety generally?
Rule of 1/3s - 1/3 recover fully, 1/3 improve partially, 1/3 fare poorly
217
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
218
Recall the possible symptoms of GAD
```
Restlessness
Irritability
Fatiguability
Muscle tension
Sleep disturbance
Poor concentration
```
219
How many symptoms need to be present most of the time for a GAD diagnosis?
3
220
What questionnaire is useful in diagnosis of GAD?
GAD-7
| Beck's anxiety inventory/ HADS can also be used
221
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
222
Which treatments should not be used in phobias?
1. BDZs (high risk of dependence)
| 2. Antidepressants - specific phobias don't respond well
223
What is agarophobia?
Fear of leaving home/ entering shops/ crowds/ public places etc
224
Into which 2 classifications is agarophobia classified?
As either with or without a panic disorder
225
How is agarophobia managed?
1. Education, reassurance and self-help
2. Exposure Response Prevention
3. CBT
226
What is social phobia?
The fear of scrutiny of other people leading to avoidance of social situations
227
How can social phobia and agarophobia be differentiated?
In social phobia they will tolerate anonymous crowds but smaller groups will spike anxiety
228
How can specific phobias managed?
Education/ self-help/ Exposure Response Prevention
| BDZs can be given short term
229
What is panic disorder?
Recurrent attacks of severe anxiety that are not restricted to any particular circumstances and are therefore unpredictable
230
What is the maximum duration of a panic attack?
30 mins
231
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
232
What is OCD?
Disorder that may have recurrent obsessional thoughts or compulsive acts
233
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
234
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
```
235
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
236
Describe the gender balance of OCD prevalence?
Only anxiety disorder to affect men more than women
237
Which part of the brain can be implicated in OCD?
Basal ganglia
238
What is the rating scale that should be used for OCD?
Yale-Brown OCD scale
239
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?
240
How should OCD with mild functional impairment be managed?
CBT with Exposure Response Prevention
241
How should OCD with moderate functional impairment be managed?
Intensive CBT with ERP or SSRI
242
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
243
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)
244
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
245
What are the key features of adjustment disorder?
Initial daze, constriction of conscious field, narrowing of attention, inability to comprehend stimuli, disorientation
246
How should adjustment disorder be managed?
Support and reasurance, may give BDZs for short-term distress
247
What may increase the risk of progression to PTSD from adjustment disorder?
Formal, immediate, psychological 'debriefing'
248
How long can adjustment disorder last?
No longer than 6 months
249
Describe the presentation of adjustment disorder
Symptoms of anxiety and depression, without biological symptoms of depression
250
What would make a grief reaction abnormal/ prolonged?
Delayed onset, increasing intensity of symptoms, suicidal idealisation, hallucinatory experiences
251
For how long do symptoms need to persist in order to make a diagnosis of PTSD?
1 month
252
What are the key signs and symptoms of PTSD?
1. Re-experiencing
2. Avoidance of triggers
3. Hyperarousal
253
Which questionnaire should be used in suspected PTSD?
Trauma screening questionnaire
254
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)
255
What mnemonic can be used for investigating substance misuse in the history?
```
TRAP:
T = type
R = route
A = amount
P = pattern
```
256
Recall the features of dependency
```
Tolerance
Craving
Withdrawal
Difficulty controlling
Continuing despite negative consequences
Primacy (neglecting other interests)
(reinstatemnt)
(narrowing of repetoire)
```
257
What is the recommended maximum alcohol intake per week?
<14 U (both men and women)
258
How many units EtOH per week are associated with hazardous and harmful drinking?
```
Hazardous = 15-35 units per week
Harmful = > 35 units/ week
```
259
What type of hallucinations may occur in delirium tremens?
Liliputian (seeing little people)
260
What type of seizure might present in alcohol withdrawl syndrome?
Grand-mal
261
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)?
262
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)
263
What alcohol screening tool is used in AandE?
FAST (fast alcohol screening test)
264
What is the triad of symptoms in Wernicke's encephalopathy?
Ataxia, opthalmoplegia, confusion
265
How many units a day does someone need to drink in order to be admitted as an inpatient for withdrawal?
>30 U per day
266
What are the 1st line chronic treatments for alcohol withdrawal?
Acamprosate/ naltrexone
267
What drug should be administered in the case of an alcohol withdrawl seizure?
IV lorazepam
268
What drugs should be administered in delirium tremens?
Oral lorazepam and IV thiamine/ pabrinex
269
What is the mechanism of action of acamprosate?
Enhances GABA transmission to remove craving for alcohol
270
What psychological therapy is appropriate in alcohol detox?
Motivational interviewing
271
What structure is damaged by B12 deficiency?
Mammillary damage
272
What are the symptoms of Wernicke's encephalopathy?
Ataxia, opthalmoplegia, acute confusion (TRIAD)
273
What are the symptoms of Korsakoff's psychosis?
Anterograde amnesia, confabulation, peripheral neuropathy, cerebellar degenration
274
From what plant are opiates derived?
Papaver somniferum
275
What is the most serious infection that you can get from injecting heroin?
Hepatitis C
276
Recall 4 local complications of heroin injection
Abscess, cellulitis, DVT, emboli (AbCDE) + pseudoaneurysm
277
Recall 4 systemic complications of heroin injection?
Septicaemia, infective endocarditis, blood-borne infections, risk of OD
278
Recall the symptoms of heroin intoxication
Euphoria and 'warmth'
OD: pinpoint pupils and low RR
Low-dose side effects: constipation, anorexia, decreased libido
279
How should opiate OD be treated?
Naxolone
280
What are the symptoms of opiate withdrawal?
Craving, insomnia, agitation, flu-like symptoms, the 'runs' (D+V, lacrimation, rhinorrhoea), goose flesh, mydriasis
281
How long after injection of heroin do withdrawal symptoms begin?
6 hours after injection
282
How long do opiate withdrawal symptoms last?
5-7 days
283
How long do opiates stay in the urine?
2 days
284
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
285
What are the two stages of Opiate Substitution Therapy?
Stabilisation and detoxification
286
How long does Opiate Substitution Therapy last as an outpatient?
12 weeks minimum
287
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
288
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
289
What is the minimum duration of follow-up care following opiate detoxification?
6 months
290
For how long following last use is cannabis present in urine?
4 weeks
291
Recall some chronic complications of cannabis use
Dysthymia, anxiety/ depressive illness, amotivational syndrome
292
Recall 4 types of hallucinogenic drug
LSD, phencyclidine, ketamine, magic mushrooms
293
How long can an LSD trip last?
12 hours
294
What is a street name for phencyclidine?
Angel dust
295
What are the symptoms of phencyclidine use?
Violent outbursts and ongoing psychosis
296
Recall the symptoms of ketamine use in smaller and larger doses
```
Smaller = dissociation
Larger = hallucinations and synaesthesia
```
297
Recall the symptoms of magic mushroom use in smaller and larger doses
```
Small = euphoria
Large = hallucinations
```
298
What can be used to treat hallucinogen withdrawal short term?
BDZs
299
What stimulant is most often used in East African communities?
Khat/ quat/ chat
300
Which recreational stimulant drug class may cause dependence?
Amphetamines
301
Recall some acute side effects of cocaine use
Arrhythmia, intense anxiety, HTN
302
Recall some chronic side effects of cocaine use
Nasal septum necrosis, foetal damage, panic and anxiety, delusions, psychosis
303
How can ecstasy cause death?
Via dehydration and hyperthermia
304
Recall the 2 phases of cocaine withdrawal
1. Crash phase - depression, agitation, irritability
| 2. Withdrawal - poor concentration, insomnia, slowed movements
305
How long does cocaine remain in urine?
5-7 days
306
What is the most significant risk of BDZ use?
Dependence
307
What is the result of BDZ overdose?
Respiratory depression
308
How should BDZ overdose be treated?
IV flumenazil
309
What are the 2 options for BDZ withdrawal management?
1. Slow-dose reduction
| 2. Switch to diazepam equivalent dose and then slow-dose reduction
310
What is the most common side effect of BDZ withdrawal?
Anxiety
311
At what rate should BDZ dose be reduced?
1/8th dose every 2 weeks
312
What are the 3 medical options for smoking cessation?
Nicotine replacement therapy, varenicline, bupropion
313
What is the mechanism of action of Varenicline and Bupropion?
```
Varenicline = partial nicotine receptor agonist
Bupropion = selective DA and NA reuptake inhibitor (weak)
```
314
How long before the quit date should Bupropion and Varencline be started?
7-14 days
315
Recall some contraindications for varenicline
<18 y/o, renal disease
316
Recall some contraindications for bupropion
<18 y/o, seizures, CNS disorder, eating disorder, BPAD, cirrhosis
317
Recall the 3 Ps necessary to diagnose personality disorder?
Persistent, pervasive and pathological
318
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
319
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)
320
What is the supposed prevalence of personality disorder?
10%
321
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
322
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
```
323
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
```
324
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
```
325
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
```
326
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
```
327
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
```
328
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
```
329
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
```
330
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'
331
In which conditions may splitting be seen?
EUPD/ BPD
332
What does 'dissociation' describe in personality disoder?
An immature ego defence where one assumes a differerent identity to deal with a situation
333
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)
334
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)
335
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)
336
What is 'displacement' in personality disorder?
Defence mechanism whereby someone takes out their emotions on a neutral person
337
What is 'projection' in personality disorder?
Where a person assumes an innocent or neutral character is guilty for the patient's actions
338
Which medications might be used in cluster A personality disorders?
None
339
Which medications might be used in cluster B personality disorders?
antipsychotics, antidepressants and lithium
340
Which medications might be used in cluster C personality disorders?
Lithium
341
In which personality disorders is dialetical behaviour therapy particularly useful?
EUPD/BPD
342
What are the 2 concepts introduced by DBT?
Validation (your emotions are acceptable)
| Dialectics (things in life are rarely black and white)
343
Which eating disorder is most genetically heritable?
Anorexia nervosa
344
How can you test for proximal myopathy?
Squat test
345
What is the expetced T4 thyroid measurement in patients with an eating disorder?
Low
346
What ECG abnormality may be present in bulimia nervosa?
Long QT
347
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
```
348
What is required for anorexia nervosa diagnosis in the ICD-10?
1. BMI < 17.5
2. Deliberate weight loss
3. "Fear of the fat"
349
How are anorexia nervosa and bulimia nervosa distinguished clinically?
AN = underweight, BN = normal/ increased weight
350
What is Russel's sign?
Callous/ cut knuckles from self-induced vomiting
351
How is anorexia nervosa managed?
NO WATCHFUL WAITING - refer immediately
352
What are the AandE guidelines used for patients with anorexia nervosa?
MARISPAN (Management of Really Sick Patients with AN)
353
At what BMI should someone be referred to Community Eating Disorder Services urgently?
<15
354
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
355
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)
356
What is the duration of CBT-ED?
40 weekly sessions
357
What is the focus of MANTRA therapy for anorexia nervosa?
Focusing on the cause of the anorexia nervosa
358
Describe SSCM treatment for anorexia nervosa
Explore problems of anorexia, educate on nutrition and eating habits, explore a future beyond anorexia
359
What is the target weight gain range for AN patients?
0.5-1.0kg/ week
360
When should pharmacological managemrnt be used in AN?
If physical symptoms, rapid weight loss or BMI <13.5
361
What is the appropriate drug for pharmacological treatment of AN?
Fluoxetine
362
What are the first and second line treatments for children with AN?
1st line = family therapy
| 2nd line = ED-CBT
363
What is the main defining feature of the Refeeding Syndrome?
Low phosphate
364
What is the aetiology of the refeeding syndrome?
Intracellular shift in (already low) ions due to insulin release upon refeeding
365
Which electrolytes are low in the refeeding syndrome?
Low K+, low phosphate, low magnesium
366
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?
367
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)
368
What is BED?
Binge eating disorder - most common ED, does not include purging pathology
369
How should bulimia nervosa be managed?
Like anorexia, refer immediately and screen for immediate admission (most are managed in the community)
370
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)
371
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
372
What is dissociative fugue?
Dissociative amnesia + purposeful travel beyond everyday range
373
What is a dissociative stupor?
Lack of voluntary movement/ normal responses to external stimuli
374
What are trance and posession disorders?
Temporary loss of personal identity and full sense of awareness of surroundings
375
What part of the body is affected by dissociatve motor disorders?
Limbs
376
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
377
How can dissociative anaesthesia be distinguished from organic anaesthesia?
Areas of anaesthesia do not follow normal dermatomal distribution
378
How is somatisation defined?
Multiple, recurrent and frequently changing physical symptoms of 2 years duration without evidence of underlying organic cause
379
Recall the 4 subtypes of somatisation disorder
1. Undifferentiated somatoform disorder
2. Hypochondrial disorder
3. Somatoform autonomic dysfunction
4. Persistent somatoform pain disorder
380
What are the hallmark features of hypochondrial disorder?
Often cancer
| Pre-occupation with a single problem
381
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)
382
What is the age-limit for early-onset dementia?
65 years old
383
What are the 2 most useful screening questionnaires for dementia?
AMTS, GPCOG
384
What AMTS score suggests cognitive impairment?
<7
385
What is the most detailed assesment of possible dementia?
Addenbrooke's (ACE-R) - 100 questions
386
How many questions are in the MMSE?
30
387
What would be the appearance on MRI of a brain affected by Alzheimer's?
Grey matter atrophy, wide ventricles and sulci, temporal lobe atrophy
388
What biomarker can be used to identify Lewy Body dementia?
123|-FP-CIP SPECT
389
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)
390
Which region of the brain is the first to be affected by Alzheimer's disease?
hippocampus
391
Recall 4 genetic risk factors for Alzheimer's
Presenelin 1
Presenelin 2
Beta-amloid precursor protein gene
Co-existent Downs syndrome
392
What are the 4 key elements of pathophysiology in Alzheimer's?
Atrophy from neuronal loss
Plaque formation
Neurofibrilliary tangles
Cholinergic loss
393
How does Alzheimer's characteristically present?
The 4 'A's:
- Amnesia
- Aphasia
- Agnosia
- Apraxia
394
If a short-term antipsychotic is required in Alzheimer's disease, which is most appropriate?
Risperidone
395
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
```
396
What is the first line option for psychological management of Alzheimer's?
Structural group cognitive stimulation
397
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
398
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
399
How should vascular dementia be managed?
```
Manage RFs (daily aspirin, dietary advice, stop smoking etc)
Same psychological treatment as alzheimer's dementia
```
400
What are Lewy bodies composed of?
Alpha synuclein with ubiquitin
401
Describe the distribution of Lewy bodies in Lewy Body Dementia vs Parkinsons disease
LBD = brainstem, cingulate gyrus and neocortex
| In PD = just brainstem
402
Describe the classical presentation of Lewy body dementia
Fluctuating confusion with marked variations in alertness levels
403
What confusing symptoms may be seen in Lewy body dementia?
Lilliputian hallucinations (like delirium)
Parkinsonianism
Frequent falls
404
What is an important medication NOT to offer in Lewy body dementia?
Antipsychotics - they increase risk of cerebrovasvular disease
405
What medical management can be used in Lewy body dementia?
Same as Alzheimers disease - anti-cholineesterases
406
What is another name for frontotemporal dementia?
Pick's disease
407
What is especially unusual about frontotemporal dementia?
Early onset (usually 40 to 60 years)
408
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)
409
What two investigations are most useful in frontotemporal dementia?
FDG-PET (fluorodeoxyglucose), MRI (to see frontal lobe shrinkage)
410
What is the prognosis for frontotemporal dementia?
Death in 5-10 years
411
What is the inheritance pattern of Huntingdon's?
Autosomal dominant so 50% chance of children inheriting
412
When in the life-course is the onset of Huntingdon's?
30-50 years old
413
What is the general clinical picture of Huntingdon's?
Clumsy, speech difficulties
414
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%
415
What are chorea?
Involuntary jerking movement that tend to flow from one area to another
416
What is the model for formulation in CAMHS?
Biological, psychological and social for the 4 'P's: predisposing, precipitating, perpetuating and protecting
417
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
418
What rating scale can be used to asses ADHD?
Conner's Comprehensive Behaviour Rating Scale (age 6-18)
419
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
```
420
What are some side effects of methylphenidate?
Abdo pain, nausea, dyspepsia
421
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)
422
What % of children with ADHD have it as an adult?
15%
423
What medication during pregnancy can increase risk of Autism spectrum disorder?
Sodium valporate
424
Recall 4 important associations of ASD
Fragile X syndrome
Tuberous sclerosis
Neurofibromatosis
Di-George
425
What is the difference between Asperger's and Autism?
Asperger's has no delay in language/ cognitive development
426
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
427
What is the most common form of ASD?
Pervasive Developmental Disorder Not Otherwise Specified (PPD-NOS)
428
In what 3 spheres of life are there abnormalities in Autistic spectrum disorder?
Social interaction
Communication
Patterns of behaviour/ interests/ activities
429
What are the typical motor mannerisms of children with ASD?
Finger flapping and repetitive whole-body movements
430
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
431
What is one hallmark symptom of Autism spectrum disorder?
Echolalia
432
Recall the 2 gold standard diagnostic tools for ASD
1. ADI-R (autism diagnostic inventory - revised)
| 2. ADOS (Autism Diagnostic Observatory Schedule)
433
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
434
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
435
In which age group can oppositional defiant disorder exist?
<10 years old
436
For how long must symptoms persist for a diagnosis of conduct disorder?
6 months
437
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
438
By what 3 criteria is learning difficulty defined?
IQ < 70, impaired social/ adaptive functionning, onset in childhood
439
At what IQ level is the cause of LD considered to be always organic?
IQ <50
440
What is the most prevalent physical symptom of learning difficulties?
Poor sleep/ wake cycle
441
What scale is used to assess intellectual impairment?
WAIS II
442
What medications might be useful in learning difficulties?
Melatonin for sleep
443
Which law protects reasonable adjustment?
Disability act 1995
444
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
445
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
446
How long after a change in lithium dose should the levels be taken?
7 days later and 12 hours following last dose
447
What electrolyte abnormality is associated with SSRIs?
Hyponatraemia
448
What is the anti-depressant of choice following a myocardial infarction?
Sertralline
449
What is acute dystonia?
Sustained muscle contraction (eg oculogyric crisis, torticollis)
450
How can acute dystonia be managed?
Procyclidine
451
What is acute dystonia a side effect of?
Antipsychotics (typical and atypical alike)
452
What is the most common endocrine disorder developing as a result of chronic lithium toxicity?
Hypothyroidism
453
What is the main risk of using paroxetine in pregnancy?
Congenital malformations
454
Which antipsychotic reduces the seizure threshold?
Clozapine
455
What drug can be used to treat tardive dyskinesia?
Tetrabenazine
456
What is the main risk of SSRI use in the third trimester of pregnancy?
Persistent pulmonary hypertension of the newborn
457
What are the metabolic side effects of antipsychotics?
Hyperlipidaemia
| Diabetes mellitus
458
How should antidepressant medication be managed prior to ECT treatment?
The dose should be reduced but not stopped
459
What is the most prominent symptom of SSRI-discontinuation syndrome?
Diarrhoea
460
What type of incontinence can be caused by TCAs?
Overflow incontinence
461
Which psychiatric drug can cause hyperparathyroidism?
Lithium
462
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
463
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)
464
How do bromocriptine and dantrolene work to treat the NMS?
Bromocriptine reverses dopamine blockade
Dantrolene reduces muscle spasm
ECT
