MENTAL HEALTH

Question 1

Lewy body dementia treatments

Answer 1

Donepezil is a cholinesterase inhibitor which is the first-line treatment for cognitive impairment and behavioural symptoms in DLB.

Carbidopa/Levodopa are dopaminergic agents used to treat motor symptoms which present in Lewy body dementia

Clonazepam is used to treat REM sleep behaviour disturbances and should be given in low doses 30 minutes before bedtime.

Sertraline is an SSRI which are the preferred drugs to treat depression with Lewy body dementia because they have limited side-effects and favourable pharmacokinetics

Question 2

Hypertrophic obstructive cardiomyopathy - is associated with

Answer 2

Wolff-Parkinson White

Question 3

kidny stones gold standard investigation

Answer 3

The gold standard investigation is a spiral non-contrast CT scan.

Question 4

Adult-onset Still’s disease features

Answer 4

Features
arthralgia
elevated serum ferritin
rash: salmon-pink, maculopapular
pyrexia
typically rises in the late afternoon/early evening in a daily pattern and accompanies a worsening of joint symptoms and rash
lymphadenopathy
rheumatoid factor (RF) and anti-nuclear antibody (ANA) negative

Question 5

Adult-onset Still’s disease management

Answer 5

Management
NSAIDs
should be used first-line to manage fever, joint pain and serositis
they should be trialled for at least a week before steroids are added.
steroids
may control symptoms but won’t improve prognosis
if symptoms persist, the use of methotrexate, IL-1 or anti-TNF therapy can be considered

Question 6

Short-term side-effects of ECT

Answer 6

Short-term side-effects
headache
nausea
short term memory impairment
memory loss of events prior to ECT
cardiac arrhythmia

Question 7

Erotmania

Answer 7

specific form of delusional disorder that is characterised here by the patient’s belief that a famous actor is in love with her, alongside no other symptoms suggesting psychosis or mood disturbance.
Other subtypes of delusion include grandiose and persecutory.

Question 8

Antipsychotics in the elderly

Answer 8

ncreased risk of stroke and VTE

Question 9

Anorexia features

Answer 9

most things low

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

Question 10

r borderline personality disorder

Answer 10

Efforts to avoid real or imagined abandonment
Unstable interpersonal relationships which alternate between idealization and devaluation
Unstable self image
Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse)
Recurrent suicidal behaviour
Affective instability
Chronic feelings of emptiness
Difficulty controlling temper
Quasi psychotic thoughts

Question 11

personality disorder management

Answer 11

Management
PDs are often thought to be ‘untreatable’ by definition
however, a number of approaches have been shown to help patients, including:
psychological therapies: dialectical behaviour therapy

Question 12

Schizotypal

Answer 12

Ideas of reference (differ from delusions in that some insight is retained)
Odd beliefs and magical thinking
Unusual perceptual disturbances
Paranoid ideation and suspiciousness
Odd, eccentric behaviour
Lack of close friends other than family members
Inappropriate affect
Odd speech without being incoherent

Question 13

Schizoid

Answer 13

Indifference to praise and criticism
Preference for solitary activities
Lack of interest in sexual interactions
Lack of desire for companionship
Emotional coldness
Few interests
Few friends or confidants other than family

Question 14

Histrionic

Answer 14

Inappropriate sexual seductiveness
Need to be the centre of attention
Rapidly shifting and shallow expression of emotions
Suggestibility
Physical appearance used for attention seeking purposes
Impressionistic speech lacking detail
Self dramatization
Relationships considered to be more intimate than they are

Question 15

NICE published guidelines on the management of schizophrenia in 2009.

Answer 15

Key points:
oral atypical antipsychotics are first-line
cognitive behavioural therapy should be offered to all patients
close attention should be paid to cardiovascular risk-factor modification due to the high rates of cardiovascular disease in schizophrenic patients (linked to antipsychotic medication and high smoking rates)

Question 16

Rapid tranquillisation

Answer 16

• intramuscular lorazepam on its own or intramuscular haloperidol combined with intramuscular promethazine for rapid tranquillisation in adults.
• If there is insufficient information to guide the choice of medication for rapid tranquillisation, or the service user has not taken antipsychotic medication before, use intramuscular lorazepam.

Question 17

haemophilia A cause

Answer 17

clotting factor VIII deficiency

Question 18

haemophilia B cause

Answer 18

which is caused by a factor IX deficiency

Question 19

Typical symptoms of haemophilia may include

Answer 19

Severe epistaxis
Bleeding gums
Haematuria: gross or microscopic (i.e. detected on dipstick).
Intra-articular or intramuscular bleeds: commonly affected joints include the knees, ankles and elbows.
Excessive bruising/ecchymoses, contusions or spontaneous haemorrhage during childhood play.
Prolonged bleeding after a surgical or dental procedure, or post-venepuncture.

Question 20

Findings associated with haemophilia include:

Answer 20

Normal platelet count on FBC
Normal prothrombin time (PT), bleeding time (BT), fibrinogen levels and von Willebrand factor levels.
Prolonged activated partial thromboplastin time (APTT): although this can be normal in mild disease.
Reduced factor VIII or factor IX activity level: for haemophilia A or B respectively.

Question 21

haemophilia vs VWD

Answer 21

Haemophilia A/B/C only APPT increased

VWD Bleeding time increase APPT normal or increased

Question 22

ADHD management

Answer 22

DHD is managed with behavioural techniques and stimulant medicines such as methylphenidate. These medicines increase function of the frontal lobe to increase executive function to increase attention and reduce impulsivity.

ADHD may impair a child’s ability to perform well at school, and they might benefit from extra support. However, ADH does not generally affect intellectual ability.

Question 23

e Mental Capacity Act - 5 key principles

Answer 23

A person is assumed to have capacity unless proven otherwise
Steps must be taken to help a person have capacity
An unwise decision does not mean a person lacks capacity
Any decisions made under the MCA must be in the person’s best interests
Any decisions made should be the least restrictive to a person’s rights and freedoms

Question 24

Munchausen’s syndrome:

Answer 24

patients intentionally fake signs and symptoms (e.g. adding blood to urine and complaining of pain) in order to gain attention and play “the patient role”.

Question 25

ECT in depression

Answer 25

For severe depressive episodes that are life-threatening or require a rapid response, NICE guidelines recommend Electroconvulsive Therapy (ECT). It is not known exactly how ECT works but there is evidence to suggest that the induced seizure has more of a treatment effect than 'placebo' ECT or 'sham' ECT. Short-term side effects of ECT can include headache, muscle aches or pains, nausea, temporary memory loss, confusion. Long-term side effects of ECT can include persistent memory loss. Due to the induced seizure, there is a risk of damage to the teeth or mouth, and due to the general anaesthetic, there is a small risk of death.

Question 26

CO2 poisoning treatment

Answer 26

Treatment is largely supportive, with 100% oxygen and early intensive care involvement. Hyperbaric oxygen can be considered in more serious cases.

Question 27

Obstructive sleep apnoea

Answer 27

A diagnosis of OSA is made using sleep studies. Treatment of OSA includes lifestyle changes such as weight loss and smoking cessation; night time CPAP and consideration of surgical interventions.

Question 28

nausea, vomiting, colicky pain and increased secretions can be treated with a number of agents;

Answer 28

Hyoscine butylbromide Octreotide Ondansetron Atropine

Question 29

a fib management

Answer 29

According to the NICE guidelines; Rate control should be offered first line, except for patients with new onset AF, reversible causes or heart failure. Rate can be controlled using a beta blocker or calcium channel blocker Digoxin should be considered in patients with heart failure Amiodarone should not be given for long term rate control Rhythm control can be pharmacological or by electrical rhythm control DC cardioversion should be done in patients with unstable atrial fibrillation Patients with new onset AF should be started on anti-coagulation as they are high risk for stroke

Question 30

Clozapine Mac and side effects/risk

Answer 30

Dibenzodiazepine (tricyclic derivative) • Works in treatment resistant schizophrenia (no one knows why) • Reduces suicide risk • It causes agranulocytosis in 1% • Thus there is a national monitoring system in place: a recent FBC result is mandatory for dispensing. • Tachycardia is common s/e. Rarely, it causes myocarditis (usually 1st month of treatment). • Stronglyassociatedwithgastrointestinalhypomobility– obstruction -> toxic megacolon. • Very sedating (but that’s not why it works better) • Low risk of EPSEs • Reducesseizurethreshold • Serum monitoring has utility – 0.35 - 0.6 mmol/L

Question 31

Lithium

Answer 31

Effective in type 1 bipolar disorder • Antimanic and antidepressant. Better for prophylaxis than acute treatment (use antipsychotic) • Reduces suicide risk • *MUST BE PRESCRIBED BY BRANDNAME* e.g. Priadel, camcolit. • Must check U+Es, TFTs prior to Rx. • Trough level (12 hours post dose) serum monitoring is essential • Aim for serum levels between 0.6-0.8 mmol/L. • Narrow therapeutic index. DANGEROUS IN OVERDOSE. • Long term side effects are renal failure and thyroid dysfunction • Adverse interactions with NSAIDs and many diuretics -> leads to toxic levels -> BEWARE!

Question 32

Monoamine Oxidase Inhibitors

Answer 32

Phenelzine (most common), isocarboxazid and tranylcypromine • Irreversibly bind monoamine oxidase type A in the CNS • Can cause sympathomimetic crises (malignant hypertension) in combination with a high tyramine diet • Conversely, the most common side effect is postural hypotension, also insomnia and GI disturbances. • Probably underused now – particularly for TRD • Not as dangerous as they are made out to be. Nonetheless, specialist only prescription. We use them at the Maudsley. • If prescribed with SSRIs, then high risk of serotonin syndrome (potentially fatal). They can be prescribed with NET TCAs and mirtazapine, agomelatine, trazodone, lithium etc. • Phenelzine and isocarboxazid (not tranylcypromine) irreversibly bind pyridoxine (Vit. B6). In theory -> skin problems, glossitis, neuropathy. Very rare. • Low threshold for seeking highly specialist advice (Maudsley National Affective Disorders Service, or local equivalent) if your patient is having problems with them. Most psychiatrists don’t know how to manage them.

Question 33

Sodium Valproate

Answer 33

Antiepileptic with antimanic, mood stabilising properties (also used in migraine) • Commonly prescribed in bipolar disorder (sometimes as divalproex or valproic acid (same thing)) • It is a teratogen • 1 in 10 babies have serious congenital abnormalities • 4 in 10 babies have neurodevelopmental disorders • In 2018, the MHRA banned its use in women of childbearing age unless they were on a fool proof method of contraception and signed a yearly declaration confirming knowledge of risks. Monitor with LTF's

Question 34

Neuroleptic Malignant Syndrome

Answer 34

Muscle cramps, tremor, fever, sweating, autonomic instability, rhabdomyolysis, renal failure, agitation -> delirium -> coma -> death • Medical emergency • More common with 1st gen. antipsychotics but can occur with any • Treatment is cooling, dantrolene (+/- bromocriptine), benzodiazepines, stopping all antipsychotics. • Early identification -> much lower mortality rate • A similar syndrome can occur in the absence of antipsychotics -> malignant catatonia. Similar treatment. • Rule out an organic cause -> autoimmune/infective encephalitis, illicit drugs etc.

Question 35

Serotonin Syndrome

Answer 35

Similar to NMS, but occurs with ≥2 serotonergic drugs • Rare (I’ve never seen it in clinical practice) • Muscle cramps, tremor, fever, sweating, autonomic instability, rhabdomyolysis, renal failure, agitation -> delirium -> coma -> death • Medical emergency • Most dangerous combination is MAOi + SSRI or SERT TCA. • Also occurs with high doses of MDMA (ecstacy), amphetamine, cocaine • Treatment is supportive, cyproheptadine, benzodiazepines, stopping all antidepressants, olanzapine (5HT antagonist). • Early identification -> much lower mortality rate

Question 36

Management of generalised anxiety disorder (GAD)

Answer 36

NICE suggest a step-wise approach: step 1: education about GAD + active monitoring step 2: low intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups) step 3: high intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information step 4: highly specialist input e.g. Multi agency teams Drug treatment NICE suggest sertraline should be considered the first-line SSRI if sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI) examples of SNRIs include duloxetine and venlafaxine If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first mont

Question 37

Management of panic disorder

Answer 37

Again a stepwise approach: step 1: recognition and diagnosis step 2: treatment in primary care - see below step 3: review and consideration of alternative treatments step 4: review and referral to specialist mental health services step 5: care in specialist mental health services Treatment in primary care NICE recommend either cognitive behavioural therapy or drug treatment SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered

Question 38

Medically-unexplained symptoms | Somatisation disorder

Answer 38

Somatisation disorder multiple physical SYMPTOMS present for at least 2 years patient refuses to accept reassurance or negative test results

Question 39

hypochondriasis presentation

Answer 39

llness anxiety disorder (hypochondriasis) persistent belief in the presence of an underlying serious DISEASE, e.g. cancer patient again refuses to accept reassurance or negative test results

Question 40

Conversion disorder

Answer 40

Conversion disorder typically involves loss of motor or sensory function the patient doesn't consciously feign the symptoms (factitious disorder) or seek material gain (malingering) patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies

Question 41

Malingering

Answer 41

fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain

Question 42

Psychosis

Answer 42

Psychotic features include: hallucinations (e.g. auditory) delusions thought disorganisation alogia: little information conveyed by speech tangentiality: answers diverge from topic clanging word salad: linking real words incoherently → nonsensical content

Question 43

Post-partum mental health problems screening

Answer 43

The Edinburgh Postnatal Depression Scale may be used to screen for depression: 10-item questionnaire, with a maximum score of 30 indicates how the mother has felt over the previous week score > 13 indicates a 'depressive illness of varying severity' sensitivity and specificity > 90% includes a question about self-harm

Question 44

'Baby-blues'

Answer 44

Seen in around 60-70% of women Typically seen 3-7 days following birth and is more common in primips Mothers are characteristically anxious, tearful and irritable Management = reassure and health visitor

Question 45

Postnatal depression presentation

Answer 45

Affects around 10% of women Most cases start within a month and typically peaks at 3 months Features are similar to depression seen in other circumstances

Question 46

Postnatal depression management

Answer 46

As with the baby blues reassurance and support are important Cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine* may be used if symptoms are severe** - whilst they are secreted in breast milk it is not thought to be harmful to the infant * paroxetine is recommended by SIGN because of the low milk/plasma ratio * *fluoxetine is best avoided due to a long half-life

Question 47

Puerperal psychosis features

Answer 47

Affects approximately 0.2% of women Onset usually within the first 2-3 weeks following birth Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)

Question 48

Puerperal psychosi

Answer 48

Admission to hospital is usually required There is around a 25-50% risk of recurrence following future pregnancies

Question 49

Management of cocaine toxicity

Answer 49

in general, benzodiazepines are generally first-line for most cocaine-related problems chest pain: benzodiazepines + glyceryl trinitrate. If myocardial infarction develops then primary percutaneous coronary intervention hypertension: benzodiazepines + sodium nitroprusside the use of beta-blockers in cocaine-induced cardiovascular problems is a controversial issue. The American Heart Association issued a statement in 2008 warning against the use of beta-blockers (due to the risk of unopposed alpha-mediated coronary vasospasm) but many cardiologists since have questioned whether this is valid. If a reasonable alternative is given in an exam it is probably wise to choose it

Question 50

Alcohol - problem drinking: management

Answer 50

Nutritional support SIGN recommends alcoholic patients should receive oral thiamine if their 'diet may be deficient' Drugs used benzodiazepines for acute withdrawal disulfram: promotes abstinence - alcohol intake causes severe reaction due to inhibition of acetaldehyde dehydrogenase. Patients should be aware that even small amounts of alcohol (e.g. In perfumes, foods, mouthwashes) can produce severe symptoms. Contraindications include ischaemic heart disease and psychosis acamprosate: reduces craving, known to be a weak antagonist of NMDA receptors, improves abstinence in placebo controlled trials

Question 51

Factors favouring delirium over dementia

Answer 51

impairment of consciousness fluctuation of symptoms: worse at night, periods of normality abnormal perception (e.g. illusions and hallucinations) agitation, fear delusions

Question 52

Vascular dementia RF

Answer 52

``` isk factors History of stroke or transient ischaemic attack (TIA) Atrial fibrillation Hypertension Diabetes mellitus Hyperlipidaemia Smoking Obesity Coronary heart disease A family history of stroke or cardiovascular ```

Question 53

Vascular dementia presentation

Answer 53

Patients with VD typically presents with Several months or several years of a history of a sudden or stepwise deterioration of cognitive function. Symptoms and the speed of progression vary but may include: Focal neurological abnormalities e.g. visual disturbance, sensory or motor symptoms The difficulty with attention and concentration Seizures Memory disturbance Gait disturbance Speech disturbance Emotional disturbance

Question 54

Lewy body dementia features

Answer 54

Features progressive cognitive impairment in contrast to Alzheimer's, early impairments in attention and executive function rather than just memory loss cognition may be fluctuating, in contrast to other forms of dementia usually develops before parkinsonism parkinsonism visual hallucinations (other features such as delusions and non-visual hallucinations may also be seen)

Question 55

Lewy body dementia management

Answer 55

Management both acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine can be used as they are in Alzheimer's. NICE have made detailed recommendations about what drugs to use at what stages. Please see the link for more details neuroleptics should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism. Questions may give a history of a patient who has deteriorated following the introduction of an antipsychotic agent

Question 56

Factors suggesting diagnosis of depression over dementia

Answer 56

Factors suggesting diagnosis of depression over dementia short history, rapid onset biological symptoms e.g. weight loss, sleep disturbance patient worried about poor memory reluctant to take tests, disappointed with results mini-mental test score: variable global memory loss (dementia characteristically causes recent memory loss)

Question 57

Pick's disease features

Answer 57

Frontotemporal lobar degeneration (FTLD) characterised by personality change and impaired social conduct. Other common features include hyperorality, disinhibition, increased appetite, and perseveration behaviours. Focal gyral atrophy with a knife-blade appearance is characteristic of Pick's disease. Macroscopic changes seen in Pick's disease include:- Atrophy of the frontal and temporal lobes

Question 58

normal pressure hydrocephalus

Answer 58

Urinary incontinence + gait abnormality + dementia

Question 59

PTSD features

Answer 59

AT LEAST 1m re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images avoidance: avoiding people, situations or circumstances resembling or associated with the event hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating emotional numbing - lack of ability to experience feelings, feeling detached

Question 60

NICE management of PTSD

Answer 60

Management following a traumatic event single-session interventions (often referred to as debriefing) are not recommended watchful waiting may be used for mild symptoms lasting less than 4 weeks military personnel have access to treatment provided by the armed forces trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used then venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline should be tried. In severe cases, NICE recommends that risperidone may be used

Question 61

Section 2

Answer 61

Admission for assessment for up to 28 days, non-renewable The application for admission is made by an Approved Mental Health Professional (AMHP) or the patient's nearest relative Requires the recommendation of 2 doctors, one of whom must be 'approved' under Section 12(2) of the MHA

Question 62

Section 3

Answer 62

Admission for treatment for up to 6 months, renewable | Requires an AMHP and 2 doctors, both of whom must have seen the patient in the past 24 hours

Question 63

Section 4

Answer 63

Used in emergencies where a section 2 would cause “an undesirable delay” It requires the recommendation of only one doctor and either an AMHP or the nearest relative Allows a person to be detained for up to 72 hours, whereby it is usually converted to a section 2

Question 64

Section 5(2)

Answer 64

A voluntary patient in hospital may be legally detained by a doctor for 72 hours

Question 65

Section 5(4)

Answer 65

A section 5(4) is similar to a section 5(2) but is used by nurses and only lasts for 6 hours.

Question 66

Section 17a

Answer 66

Supervised Community Treatment (also known as a Community Treatment Order)

Question 67

Section 135

Answer 67

court order that allows the police to enter a property to remove a person to a Place of Safety (either the police station or more commonly A&E)

Question 68

Section 136

Answer 68

The police can bring someone from a public place who appears to have a mental disorder to a Place of Safety (either the police station or more commonly A&E)

Question 69

first rank symptom is highly suggestive of a diagnosis of schizophrenia.

Answer 69

``` Primary delusions Delusion of perception Thought insertion Thought broadcast Thought withdrawal Passivity feelings Somatic hallucinations Auditory hallucinations of third person ```

Question 70

SCZ treatment

Answer 70

First choice antipsychotic medication might include: ``` Olanzapine Resperidone Quetiapine Aripiprazole The choice of medication is usually guided by previous response, side effect profile and compliance. ``` Therapeutic Trial A minimum six week therapeutic trial is warranted before changing to a different medication. Treatment Resistance More than 25% of patients are resistant to treatment and about 12% of first episode patients do not respond to treatment at the end of the first year. Clozapine is considered the drug of choice for treatment resistant schizophreni

Question 71

DDx for phycotic symtoms

Answer 71

Encephalitis Brain tumour Epilespy Substance use

Question 72

Drug-induced psychosis

Answer 72

Acute onset Concurrent substance use Often hallucinations & delusions Often resolves in hours – days after substance stopped

Question 73

Charles Bonnet syndrome

Answer 73

adjustment to visual loss - phantom vision