Passmed wrong answers Flashcards
ICD-10 criteria for depressive illness
In typical depressive episodes, individuals usually suffer from depressed mood, loss of interest in things you would normally find pleasure in (anhedonia), and reduced energy levels (anergia). Other common symptoms include:
- Reduced concentration and attention
- Decreased self-esteem and confidence
- Feelings of guilt and unworthiness
- Bleak and pessimistic views of the future
- Ideas or acts of self-harm or suicide
- Disturbed sleep
- Diminished appetite and weight loss
- Psychomotor agitation or retardation
- Marked loss of libido
- Mild Depressive Episode:
At least 2 of the main 3 symptoms of depression, and at least two of the other symptoms, should be present for a definite diagnosis. None of the symptoms should be present to an intense degree
Minimum duration of the whole episode is about 2 weeks
Individuals may be distressed by symptoms, but should be able to continue work and social functioning - Moderate Depressive Episode:
At least 2 of the main 3 symptoms of depression, and at least three (and preferably four) of the other symptoms, should be present for a definite diagnosis
Minimum duration of the whole episode is about 2 weeks
Individuals will usually have considerable difficulty continuing with normal work and social functioning - Severe Depressive Episode:
All three of the typical symptoms should be present, plus at least four other symptoms, some of which should be of severe intensity
The minimum duration of the whole episode should last at least 2 weeks, but if the symptoms are particularly severe then it may be appropriate to make an early diagnosis
Can also experience psychotic symptoms with severe depressive episodes
Individuals show severe distress and/or agitation
What is the PHQ-9 and what scores indicate the types of depression?
Patient Health Questionnaire (PHQ-9)
- asks patients ‘over the last 2 weeks, how often have you been bothered by any of the following problems?’
- 9 items which can then be scored 0-3
- includes items asking about thoughts of self-harm
Less severe depression encompasses subthreshold and mild depression, and more severe depression encompasses moderate and severe depression. Thresholds on validated scales were used in this guideline as an indicator of severity
1. a score < 16 on the PHQ-9: less severe depression
2. a score of ≥ 16 on the PHQ-9: severe depression
What are the DSM-5 criteria for major depressive disorder?
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
Why is lithium not used in acute mania? What should be used instead?
Lithium is used as a mood stabiliser but can take up to 2 weeks to become effective, so a second-generation antipsychotic would be used first. Lithium would be used if the response to the antipsychotic is inadequate.
Olanzapine
What are the types of bipolar disorder?
Bipolar disorder is a chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression.
Two types of bipolar disorder are recognised:
type I disorder: mania and depression (most common)
type II disorder: hypomania and depression
What is the difference between mania and hypomania?
both terms relate to abnormally elevated mood or irritability
- with mania, there is severe functional impairment or psychotic symptoms for 7 days or more
- hypomania describes decreased or increased function for 4 days or more but < 7 days
from an exam point of view the key differentiation is psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) which suggest mania
How is bipolar disorder managed?
- psychological interventions specifically designed for bipolar disorder may be helpful
- lithium remains the mood stabilizer of choice. An alternative is valproate
management of mania/hypomania
- consider stopping antidepressant if the patient takes one; antipsychotic therapy e.g. olanzapine or haloperidol
management of depression
talking therapies; fluoxetine is the antidepressant of choice
address co-morbidities
there is a 2-3 times increased risk of diabetes, cardiovascular disease and COPD
What is the mechanism of action of benzodiazepines?
Its mechanism of action involves enhancing the effect of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter in the brain. This enhancement is achieved by increasing the frequency of chloride channel opening within the GABA-A receptor complex, leading to hyperpolarisation of neurons and ultimately decreased neuronal excitability.
Why do symptoms of alcohol withdrawal occur?
chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
Symptoms of alcohol withdrawal occur as GABA is the main inhibitory neurotransmitter in the central nervous system. This has certain binding sites for ethanol, so increases inhibition in the CNS when present. Long-term alcohol exposure to GABA results in continuous inhibition effects on the brain. Further, ethanol binds to glutamate, which is an excitatory amino acid in the CNS. When this binds to glutamate, this inhibits excitation of the CNS, worsening the inhibitory effect.
What is the timeline of symptoms following the last drink in alcohol withdrawal?
Generally:
symptoms: 6-12 hours
seizures: 36 hours
delirium tremens: 72 hours
Mild symptoms can occur within six hours of alcohol cessation and the times in this question are rough guidelines. This will vary depending on individual patient factors such as their duration of alcohol dependence, and typical use. Early symptoms can include tremors, hyperreflexia, anxiety, gastrointestinal upset, headache, and palpitations.
Moderate symptoms include hallucinations and alcohol withdrawal seizures that can occur 12 to 24 hours after cessation of alcohol and are typically generalised in nature. Approximately half of those that have a withdrawal seizure will go on to have delirium tremens. Delirium tremens is the most severe form of alcohol withdrawal and occur due to autonomic dysfunction from excitation of the CNS. Vital sign abnormalities also occur. This can present with visual hallucinations, tachycardia, hypertension, hyperthermia, agitation, and diaphoresis. These symptoms can last up to seven days after alcohol withdrawal and sometimes can progress even longer than this.
How is alcohol withdrawal treated?
patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised
- first-line: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol
- carbamazepine also effective in treatment of alcohol withdrawal
- phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures
Which factors suggest depression over dementia?
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)
What is an acute stress disorder and how is it managed?
An acute stress disorder occurs within the first 4 weeks after a person is exposed to a traumatic event (PTSD is diagnosed after 4 weeks). The first-line management is trauma-focused cognitive behavioural therapy. Benzos may be used for acute symptoms eg agitation and sleep disturbance, should only be used with caution due to addictive potential and concerns they may be detrimental to adaption
What are the features of acute stress disorder?
- intrusive thoughts e.g. flashbacks, nightmares
- dissociation e.g. ‘being in a daze’, time slowing
- negative mood
- avoidance
- arousal e.g. hypervigilance, sleep disturbance
What is the biggest risk factor for schizophrenia?
Family history
Having a parent with schizophrenia leads to a relative risk (RR) of 7.5.
Risk of developing schizophrenia
monozygotic twin has schizophrenia = 50%
parent has schizophrenia = 10-15%
sibling has schizophrenia = 10%
no relatives with schizophrenia = 1%
What are some risk factors for psychotic disorders?
Family history
Black Caribbean ethnicity
Migration
Urban environment
Cannabis use
How are SSRIs stopped?
When stopping a SSRI the dose should be gradually reduced over a 4 week period. Can cause withdrawal if stopped abruptly eg dizziness, sleep disturbance, anxiety and mood changes
What are the indications/CI for the SSRI options?
- citalopram (although may lengthen QT interval - don’t use in long QT or in combination with other meds that lengthen QT) and fluoxetine are currently the preferred SSRIs
- sertraline is useful post myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants
- SSRIs should be used with caution in children and adolescents. Fluoxetine is the drug of choice when an antidepressant is indicated
What are the SSRI interactions?
- NSAIDs: NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
- warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
- aspirin
- triptans - increased risk of serotonin syndrome
- monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome
Effects of SSRIs in pregnancy
- BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.
- Use during the first trimester gives a small increased risk of congenital heart defects
- Use during the third trimester can result in persistent pulmonary hypertension of the newborn
- Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
SSRI discontinuation symptoms
When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.
- increased mood change
- restlessness
- difficulty sleeping
- unsteadiness/dizziness
- sweating
- gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
- paraesthesia and electric shock sensations
What are the physiological abnormalities in anorexia nervosa?
hypokalaemia
low FSH, LH, oestrogens and testosterone
raised cortisol and growth hormone
impaired glucose tolerance
hypercholesterolaemia
hypercarotinaemia
low T3
What is schizotypal personality disorder?
Patients diagnosed with schizotypal personality disorder may lack close friends other than family and can have odd or eccentric behaviour, speech, and beliefs. They may display magical thinking (the false belief that unrelated events are connected despite no evidence of a causal link), ideas of reference (the false belief that innocuous events relate to oneself,) unusual perceptual disturbances, paranoid ideation, inappropriate affect, and odd but coherent speech.
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
What is schizoid personality disorder?
A person with a schizoid personality disorder may display indifference to praise and criticism, prefer time alone, lack interest in companionship or sexual interactions, and have few interests and few friends other than family
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
What is antisocial personality disorder?
A person with an antisocial personality disorder may display impulsiveness, irresponsible behaviour, repeated deception (lying, use of aliases, conning others for personal gain), lack of respect for the law or social norms, irritability and aggressiveness, lack of remorse and reckless disregard for the safety of themselves or others.
Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest;
More common in men;
Deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
Impulsiveness or failure to plan ahead;
Irritability and aggressiveness, as indicated by repeated physical fights or assaults;
Reckless disregard for the safety of self or others;
Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations;
Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
What is avoidant personality disorder?
A person with an avoidant personality disorder may avoid work and relationships due to fear of criticism or rejection, avoid taking risks due to fear of embarrassment, be preoccupied with fears of criticism or rejection in social situations, and feel socially isolated whilst craving social contact.
Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection.
Unwillingness to be involved unless certain of being liked
Preoccupied with ideas that they are being criticised or rejected in social situations
Restraint in intimate relationships due to the fear of being ridiculed
Reluctance to take personal risks due to fears of embarrassment
Views self as inept and inferior to others
Social isolation accompanied by a craving for social contact
What are the 3 clusters of personality disorders?
Cluster A: ‘Odd or Eccentric’
Paranoid
Schizoid
Schizotypal
Cluster B: ‘Dramatic, Emotional, or Erratic’
Antisocial
Borderline (Emotionally Unstable)
Histrionic
Narcissistic
Cluster C: ‘Anxious and Fearful’
Obsessive-Compulsive
Avoidant
Dependent
What is paranoid personality disorder?
Hypersensitivity and an unforgiving attitude when insulted
Unwarranted tendency to questions the loyalty of friends
Reluctance to confide in others
Preoccupation with conspirational beliefs and hidden meaning
Unwarranted tendency to perceive attacks on their character
What is EUPD?
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
What is histrionic personality disorder?
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
What is narcisstic personality disorder?
Grandiose sense of self importance
Preoccupation with fantasies of unlimited success, power, or beauty
Sense of entitlement
Taking advantage of others to achieve own needs
Lack of empathy
Excessive need for admiration
Chronic envy
Arrogant and haughty attitude
What is obsessive compulsive personality disorder
Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone
Demonstrates perfectionism that hampers with completing tasks
Is extremely dedicated to work and efficiency to the elimination of spare time activities
Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values
Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning
Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things
Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness
What is dependent personality disorder?
Difficulty making everyday decisions without excessive reassurance from others
Need for others to assume responsibility for major areas of their life
Difficulty in expressing disagreement with others due to fears of losing support
Lack of initiative
Unrealistic fears of being left to care for themselves
Urgent search for another relationship as a source of care and support when a close relationship ends
Extensive efforts to obtain support from others
Unrealistic feelings that they cannot care for themselves
What are the atypical antipsychotics?
The main advantage of the atypical agents is a significant reduction in extrapyramidal side-effects.
- clozapine
- olanzapine: higher risk of dyslipidemia and obesity
- risperidone
- quetiapine
- amisulpride
- aripiprazole: generally good side-effect profile, particularly for prolactin elevation
Adverse effects of atypical antipsychotics?
- weight gain
- clozapine is associated with agranulocytosis
- hyperprolactinaemia
The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:
- increased risk of stroke
- increased risk of venous thromboembolism
Major side effect of clozapine? other effects?
Clozapine, one of the first atypical agents to be developed, carries a significant risk of agranulocytosis and full blood count monitoring is therefore essential during treatment. For this reason, clozapine should only be used in patients resistant to other antipsychotic medication. The BNF states:
Clozapine should be introduced if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each for at least 6–8 weeks.
Adverse effects of clozapine
- agranulocytosis (1%), neutropaenia (3%)
reduced seizure threshold - can induce seizures in up to 3% of patients
constipation
myocarditis: a baseline ECG should be taken before starting treatment
hypersalivation
Dose adjustment of clozapine might be necessary if smoking is started or stopped during treatment.
How are benzos used in alcohol withdrawal?
The key parts of management involve utilising long-acting benzodiazepines and ensuring the dose gradually reduces to decrease the need for medication as the acute withdrawal period passes
Factors associated with poor prognosis for schizophrenia
- strong family history
- gradual onset
- low IQ
- prodromal phase of social withdrawal
- lack of obvious precipitant
What is a pseudohallucination?
generally accepted definition that a pseudohallucination is a false sensory perception in the absence of external stimuli when the affected is aware that they are hallucinating.
An example of a pseudohallucination is a hypnagogic hallucination which occurs when transitioning from wakefulness to sleep. These are experienced vivid auditory or visual hallucinations which are fleeting in duration and may occur in anyone. These are pseudohallucinations as the affected person is able to determine that the hallucination was not real.
Pseudohallucinations commonly occur in people who are grieving.
How is general anxiety disorder managed?
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 month
How is panic disorder managed?
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
What is sleep paralysis and how is it managed?
Sleep paralysis is a common condition characterized by transient paralysis of skeletal muscles which occurs when awakening from sleep or less often while falling asleep. It is thought to be related to the paralysis that occurs as a natural part of REM (rapid eye movement) sleep. Sleep paralysis is recognised in a wide variety of cultures
Features
paralysis - this occurs after waking up or shortly before falling asleep
hallucinations - images or speaking that appear during the paralysis
Management
if troublesome clonazepam may be used
What is neuroleptic malignant syndrome?
Neuroleptic malignant syndrome is a medical emergency which occurs in patients taking antipsychotics. It is characterised by altered mental state, generalised rigidity, fever, fluctuating blood pressure and high temperature.
What is Lithium and what is its mechanism of action?
Lithium is mood stabilising drug used most commonly prophylactically in bipolar disorder but also as an adjunct in refractory depression. It has a very narrow therapeutic range (0.4-1.0 mmol/L) and a long plasma half-life being excreted primarily by the kidneys.
Mechanism of action - not fully understood, two theories:
- interferes with inositol triphosphate formation
- interferes with cAMP formation
