Passmed - Psychiatry

Question 1

OCD mx

mild functional impairement
1st and 2nd line

If moderate functional impairment

If severe functional impairment

Answer 1

mild functional impairement
low-intensity psychological treatments: CBT incl. ERP

If this is insufficient or can’t engage in psychological therapy, then offer
choice of either a course of an SSRI or more intensive CBT (including ERP)

If moderate functional impairment
offer a choice of either a course of an SSRI (any SSRI for OCD but fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP)

If severe functional impairment
offer combined treatment with an SSRI and CBT (including ERP)

if treatment with SSRI is effective then continue for at least 12 months to prevent relapse and allow time for improvement
If SSRI ineffective or not tolerated try either another SSRI

Question 2

What is ERP?

Answer 2

ERP is a psychological method which involves exposing a patient to an anxiety provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping them engaging in their usual safety behaviour (e.g. washing their hands). This helps them confront their anxiety and the habituation leads to the eventual extinction of the response

Question 3

De Clerambault’s syndrome

Capgras syndrome

De Frégoli syndrome

Othello syndrome

Ekbom syndrome

Answer 3

De Clerambault’s syndrome - This is the presence of a delusion that a famous person is in love with them, with the absence of other psychotic symptoms as is the case, here.

Capgras syndrome - This is the delusion that a person closely related to the patient has been replaced by an impostor.

De Frégoli syndrome - This is the delusion of identifying a familiar person in various people they encounter.

Othello syndrome - This is a delusion of sexual infidelity on the part of a sexual partner.

Ekbom syndrome - This is delusional parasitosis and describes the delusion of infestation.

Question 4

Describe Hoover’s sign

Answer 4

Hoover’s sign is a quick and useful clinical tool to differentiate organic from non-organic leg paresis. In non-organic paresis, pressure is felt under the paretic leg when lifting the non-paretic leg against pressure, this is due to involuntary contralateral hip extension

Question 5

What is

Copropraxia

Echolalia

Echopraxia

Neologism

Palilalia

Answer 5

Echolalia is the repetition of someone else’s speech including the questions being asked. It is a feature of schizophrenia, typically catatonic schizophrenia which is characterised by negative symptoms including blunting of affect, alogia (poverty of speech) and avolition (poor motivation).

Copropraxia is the involuntary performing of obscene or forbidden gestures or inappropriate touching.

Echopraxia is the meaningless repetition or imitation of the movements of others.

A neologism is a made up word.

Palilalia is the automatic repetition of one’s own words, phrases or sentences.

Question 6

What kind of incontinence does amitryptiline cause?

Answer 6

TCAs cause overflow incontinence (anti cholinergic effect]

Question 7

Which atypical antipsychotic has the fewest side effects.

Answer 7

Aripiprazole

Has the most tolerable SE profile of the atypical antipsychotics, particularly prolactin elevation

Question 8

Wernickes encephalopathy

Answer 8

Ophthalmoplegia (often LR palsy and/or horizontal nystagmus)
Confusion
Ataxia (or any other cerebellum signs)

Korsakoff’s syndrome
Anterograde amnesia
Retrograde amnesia
Confabulation

Question 9

Knight’s move thinking vs flight of ideas

Answer 9

Knight’s move thinking
This is where the patient unexpectedly leaps from one idea to another without logical associations. No logical connections between ideas.

Flight of ideas also would be demonstrated by leaps from one idea to another, however there are typically discernible links between ideas.

Question 10

Taking clozapine but missed for more than 48h Mx
More than 72h Mx
No compliant or forgetful mx

Answer 10

Restart clozapine slowly
This is because restarting clozapine after >48h can make the side effects worse - BP changes, drowsiness, dizziness

More than 72
Restart clozapine slowly + more frequent blood tests for a short period

Non compliant or forgetful
Consider depot injection

Question 11

Commonest endocrine disorder as a result of chronic lithium toxicity

Answer 11

Hypothyroidism

Question 12

Management of antipsychotic SE

Akathisia
Parkinsonism
Acute dystopia
Tar dive dyskinesia

Answer 12

Propranolol is use to treat akithisia

Procyclidine use to treat parkinosism and acute dystonia

Tetrabenazine use to treat tardive dyskinesia

Question 13

Short term and long terms effects of ECT

Answer 13

Short term
Headache 
Nausea
Memory impairment
Arrhythmia
Amnesia (retrograde and anterograde)

Longterm
Very few effects
Some patients report long term memory impairment

Question 14

SE of TCAs

Answer 14

TCAs (mnemonic)
Thrombocytopenia
Cardiac (arrhythmia, MI, stroke, postural hypotension)
Anticholinergic (tachycardia, urinary retention, dry mouth, blurry vision, mydriasis, constipation) “can’t see, can’t pee, can’t spit, can’t shit” + Anticholinergic (weight gain)
Seizures

Question 15

Effect of smoking and alcohol on clozapine levels

Answer 15

Tar is a CYP450 inducer

Start/ increase smoking - can cause a drop in clozapine levels
Stopping smoking - can cause a rise in clozapine levels

Alcohol
Binge drinking can increase clozapine levels
Stopping drinking can reduce clozapine levels

Question 16

What is schizoaffective disorder?

How to dx it?

Answer 16

Schizoaffective disorder is a condition where symptoms of a psychotic disorder and mood disorder are present together during one episode, or within a few days of each other.

For a diagnosis of schizoaffective disorder, at least one typical symptom of schizophrenia must be present with the affective symptoms within the same episode. Formal thought disorders (such as circumstantiality) can form part of schizoaffective disorder. However, this patient is not demonstrating typical signs of schizophrenia (such as psychosis or hallucinations) and therefore a diagnosis of schizoaffective disorder is unlikely.

Question 17

First line mx in the acute phase of bipolar disorder

Answer 17

Quetiapine

Question 18

Patient presenting with signs and symptoms of mania/hypomania - how do you decide whether you’d refer urgently or routinely to the community mental health team?

Answer 18

Urgent referral if patient is at risk, demonstrates poor judgment in regards to employment, personal relationships, finances, driving, sexual acitivity or drug use

Question 19

Most appropriate treatment for borderline personality disorder

Answer 19

Dialectical behavioural therapy - targeted therapy that is based on CBT but has been adapted to help proplr who experience emotions very intensely

Question 20

Things that are raised in anorexia

Answer 20

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

GH protects against hypoglycaemia by reducing inhibiting glucose uptake (i presume this is why acromegaly can cause diabetes mellitus).

GH is high is that anorexia nervosa –> hypoglycaemia –> body produces more GH to counteract this and raise glucose levels

Question 21

How long can grief reaction last for?

Answer 21

Can lastup ro 6months

Question 22

PTSD symptoms

Answer 22

hyperarousal (poor concentration, insomnia, increased startle response)

re-experiencing phenomenon (flashback and nightmares)

avoidance of reminders

emotional numbing

Question 23

Organic condition differentials for anxiety disorder

Answer 23

Hyperthyroidism, cardiac disease and medication-induced anxiety

Question 24

Mirtazine moa

Answer 24

Mirtazapine is a noradrenergic and specific serotonergic antidepressant which increases release of neurotramsitters by blocking alpha2 adrenoreceptors

Question 25

Where do GPs have tomrefer psych patients for initiation of treatment?

Answer 25

You can decide to go about initiating the first-line treatment in a number of ways, referall to the CMHT or directly to a psychotherapist being the typical one.

Question 26

Differntiate between Alzheimer’s disease and depression

Answer 26

Depression presents differently in the elderly. The history of agitation, anhedonia, and sleep disturbance with a relatively high MOCA score points towards a diagnosis of depression rather than dementia. They engage poorly with the test, as compared to patients with Alzheimer’s dementia who make an attempt but are not able to answer correctly.

Patients with mild Alzheimer’s dementia score 16 on average on the MOCA. An objective finding of poor short-term memory is more common in dementia, whereas a subjective complaint of poor memory is more common in depression.

Question 27

Medication that should be avoided in parients raking SSRIs + why

Answer 27

Triptans

The co-prescription of a triptan and an SSRI can increase the risk of serotonin syndrome

Question 28

When asked about how she feels, she begins to talk about how many different kinds of feelings there are and how people in the world have some of these feelings, and whether all people have felt all feelings. She eventually tells you, without prompting, she feels really well.

What has the patient demonstrated in this situation?

derailment 
incoherent 
Tangentiality 
circumstantiality 
Pressured speech

Answer 28

This patient has demonstrated circumstantiality in her reply to the question given. This is demonstrated by the long-winded nature of her answer.

This is not derailment as the patient has remained on the subject at hand. An example of her derailing may be talking about feelings, then sadness then saying how sad the current pandemic situation is, and then talking about viruses.

The patient is coherent in this situation. An example of her becoming incoherent would be replying with nonsensical statements such as ‘feelings like this different colour and rat poison’.

Pressured speech would be evidenced by increased production of spontaneous speech. It is difficult to say this is the case on a text-based question and this would not be the best answer in this situation.

Tangentiality would be the answer if the patient began to talk about feelings, gave the answer and connected this to something else then began talking about this. For example, if she talked about feelings and how she feels sad, then sadness, then how she feels sad about animal testing for cosmetic products.

A circle comes back around eventually (Circumstantiality)
A Tangent goes off forever in another direction (Tangentiality)
A derailed train goes off the track after a little while and needs to be nudged back on (Derailment)
Pressured speech is as if there is a load of words behind a damn, then the damn breaks and it all comes flooding out
Incoherent is self explanatory

Question 29

Dizziness, electric shock sensations and anxiety are symptoms of

Answer 29

SSRI discontinuation syndrome

Question 30

SSRI of choice in people with unstable angina or recent myocardial infarction

Answer 30

sertraline

Question 31

which condition

Circumstantiality

Tangentiality

Neolgism

Clanging

Word salad

Knight’s move thinking -

Flight of ideas -
Perseveration -

Echolalia -

Answer 31

Circumstantiality - schizophrenia & OCD.

Tangentiality - schizophrenia, delerium & dementia.

Neolgism - aphasia, stroke, other brain injury, see Trumpisms e.g. covfefe.

Clanging - mania, bipolar, shizophrenia.

Word salad - dementia, shizophrenia, brain injury.

Knight’s move thinking - schizophrenia, chess players.

Flight of ideas - mania & bipolar.

Perseveration - brain injury & aphasia, ADHD & OCD, PTSD

Echolalia - Tourette’s, brain injury, schizophrenia, dementia, epilepsy

It is important to be able to distinguish flight of ideas from Knight’s move thinking, as flight of ideas is associated with mania whilst Knight’s move is associated with schizophrenia. In flight of ideas, there are discernible links between the topics that the patient jumps between, whilst in Knight’s move thinking there are no discernible links between the topics that the patient jumps between in conversation. This is known as loosening of association.

Question 32

Dementia vs depression

Answer 32

Depression is the correct answer. This is a classical presentation of pseudodementia - the most common mimic for dementia amongst elderly patients. Although there is evidence of some cognitive impairment, the key feature present is a global memory loss affecting both short and longer-term memory, over a short history of four weeks with reluctance to engage with clinical assessment. These symptoms, coupled with the recent loss of her husband, indicate a severe reactive depressive episode.

Alzheimer’s dementia is a key differential diagnosis for these symptoms given the patient’s age, though it would tend to present more gradually, with selective impairment of short-term memory, and relative sparing of longer-term memories.