Psych #1 Flashcards

Question

A 32-year-old man with schizophrenia has recently had an increase in his dose of clozapine. He presented to the emergency department unconscious with muscle rigidity. Initial blood tests revealed a raised white cell count and a creatine kinase of 5000 iu/L. Which of the following is not a common feature of neuroleptic malignant syndrome? A. Altered consciousness B. Hypothermia C. Increased creatine kinase D. Muscle rigidity E. Tachycardia

Answer 1

B – Hypothermia Neuroleptic malignant syndrome is a life-threatening neurological condition that can occur with the use of typical and atypical antipsychotics, particularly after an increase in dosage. Symptoms include pyrexia, fluctuating consciousness, muscle rigidity and autonomic dysfunction. Investigations may reveal a raised creatine kinase, raised white cell count and abnormal liver function tests. Management includes benzodiazepines, stopping the precipitating agent, and supportive measures such as oxygen, maintaining fluid balance and reducing core body temperature. Intravenous sodium bicarbonate can be used in cases of rhabdomyolysis, and dantrolene or lorazepam can be used to reduce rigidity.

Answer 2

C – Section 5(2) Section 5(2) is doctor holding power. It allows the detention of hospital inpatients (under any speciality) by the doctor responsible for their care. It lasts 72 hours (long enough to arrange a Section 2). Note that in even more acute situations patients can be stopped under common law for a short time if there is an immediate threat to their health. Section 5(4) is nurse holding power. This allows detention of informal psychiatry inpatients by nurses if there is no doctor available. It lasts 6 hours, allowing time for a more permanent Section to be administered. Section 2 is compulsory detention for assessment; when the exact diagnosis and response to treatment is unknown. Its duration is 28 days. Application for detention under this Section can be made by the patient’s nearest relative or approved social worker. It must be agreed by two doctors (one of whom must be Section 12 approved). To become approved under Section 12(2) you have to attend a specific Section 12 training course and be recommended to do so by two psychiatry consultants. Before attending training, doctors must usually hold membership to the Royal College of Psychiatrists or have at least 3 years experience in psychiatry. Section 3 allows compulsory detention for treatment when the diagnosis is already known. It lasts for 6 months, but may be renewed if necessary. It must be agreed by two doctors (one of whom must be Section 12 approved). Section 4 allows an emergency admission to hospital when there is not enough time to organize a Section 2. Its duration is 72 hours and there is no right of appeal against it. It can be arranged by one doctor. Sections 35 to 37 can be requested by a court on advice of a Section 12 approved doctor when a patient has been charged with an offence that may lead to imprisonment. Section 35 is for the purpose of producing a medical report on the psychiatric illness of the offender. The duration is 28 days. Section 36 allows treatment of the patient. It also lasts 28 days, but requires two doctors to agree on it. Section 37 is for the detention and treatment of a patient already convicted of an imprisonable offence. This also requires two doctors’ agreement and lasts 6 months. Section 17 allows for set periods of leave from the inpatient unit (with a responsible adult) to be granted by the responsible medical officer

Answer 3

A – Capgras’ syndrome Capgras’ syndrome is a delusional belief that a close acquaintance has been replaced by an identical double. It is most commonly seen in schizophrenia. Fregoli syndrome is a delusion that a persecutor is able to change into many forms and disguise themself to look like different people, much like an actor. It is named after Leopold Fregoli, an Italian actor (1867–1936) who was famous for being able to make quick changes of appearance during stage acts. Folie a` deux is when a delusion in one person becomes shared by someone close to them. A similar effect can occur in three or more people (folie a` trios, folie a` plusieurs). de Cle´rambault’s syndrome (erotomania) is a delusional belief that someone of higher social status is in love with them. It is more common in women. Couvade syndrome occurs in males around the time of the birth of their child. They experience symptoms similar to those of pregnancy, like nausea and dyspepsia. They may even suffer abdominal distension and labour-like contraction pains. The cause is not well understood, but symptoms usually resolve soon after birth.

Answer 4

B – Low self-esteem This man has developed post-traumatic stress disorder (PTSD). PTSD (shell shock) occurs secondary to a traumatic stressor (i.e. one that any ‘normal’ person would find stressful). Diagnostic features include: † Experience of a major traumatic event † Re-experiencing the trauma (nightmares, flashbacks) † Avoidance behaviour † Increased arousal (hypervigilance, insomnia, enhanced startle reaction) † Onset is delayed (but within 6 months) and the features should last 1 month The usual course is recovery, but occasionally symptoms become chronic. Risk factors for PTSD include: † Low education † Lower social class † Afro-Caribbean/Hispanic ethnicity † Female sex † Low self-esteem † Personal or family history of psychiatric problems † Prior traumatic events

Answer 5

C – Emotionally unstable, borderline type The emotionally unstable personality disorder (borderline type) is characterized by emotional instability, disturbed views of self-image, feelings of emptiness and intense, but easily broken, relationships. Self-harm is a common feature, often in an attempt to avoid abandonment. The emotionally unstable (impulsive type) personality disorder is similar, but a lack of self-control and violent outbursts are more prominent features. Histrionic individuals crave attention, are preoccupied with appearance and are inappropriately flirtatious. They may display theatrical expressions of emotions, from excessive excitement to unexpected, manipulative tantrums.

Answer 6

E – Treatment-resistant dementia Electroconvulsive therapy (ECT) may be considered as a treatment option for depression when there are severe biological features, marked psychomotor retardation or when the patient is at high risk of harm to themselves or others. Other indications for ECT include catatonia, prolonged or severe mania and neuroleptic malignant syndrome.

Answer 7

E – Malignancy Malignancy is a common cause of weight loss and should always be considered, particularly in older people who complain of tiredness and a reduced appetite. A full examination and systems review should be carried out to determine a possible site of malignancy. Thyroid dysfunction is associated with weight change. Hyperthyroidism can lead to weight loss despite a good appetite and hypothyroidism can cause weight gain without increased intake.

Answer 8

A – Maternity blues Maternity blues affects two-thirds of women postpartum. It begins 3 to 5 days after birth, and lasts no longer than 10 days. It is characterized by low mood and tearfulness, and usually recovers spontaneously. Management is by reassurance. Postnatal depression starts within 3 months of giving birth, and usually lasts less than 6 months. It affects 10% of women. Features are similar to those of depressive episodes, but some symptoms of depression (insomnia, tiredness and low libido) are normal postpartum. There may be obsessional thoughts, particularly intrusive thoughts about harming the baby. There may be an excessive concern about the baby’s health and the mother’s own adequacy as a parent. Treatment may be solely supportive or include antidepressants. The puerperium is defined as the first 6 weeks after childbirth. This is a high-risk period for developing psychiatric illness. Puerperal psychosis affects one pregnancy in 500 and has a rapid onset during the first 3 weeks after birth. There may be a prodrome of insomnia and irritability, followed by acute confusion and psychosis. It should be treated as a medical emergency in a specialist centre because there is a suicide risk of 5% and an infanticide risk of 4%. Seventy percent of cases recover fully. The aims of treatment are to keep the mother and child together in a safe environment, and electroconvulsive therapy is sometimes required Pseudocyesis describes the presence of the signs and symptoms of pregnancy in the non-pregnant woman (e.g. amenorrhoea, breast enlargement and significant abdominal distension).

Answer 9

D – Pseudodementia Pseudodementia is recognized in people with severe depression. Their apparent cognitive dysfunction is heavily affected by their lack of motivation. The mood disturbance precedes the cognitive impairment and patients may not try to answer during formal assessments, often providing ‘don’t know’ responses to questions asked. They are more likely to complain of memory loss whereas someone with true dementia is more likely to confabulate and try to hide it. Depressive pseudodementia is a diagnosis of exclusion in someone with depression, and management aims to treat the underlying mood disorder. Creutzfeldt–Jakob disease (CJD) is a rapidly progressive dementia caused by prions (an infectious agent composed only of protein). The prion proteins can be transmitted by neurosurgical instruments and human-derived pituitary hormones. Features of CJD include rapid cognitive impairment, which may be preceded by anxiety and depression. Eventually physical features become prominent, including muscle disturbance (rigidity, tremor, wasting, spasticity fasciculations, cyclonic jerks, choreoathetoid movements). Convulsions may also occur. The EEG is characteristic (showing stereotyped sharp wave complexes). Death occurs within 6 to 8 months. HIV-related dementia (also known as AIDS dementia complex) occurs years after initial infection. It presents with reduced cognitive function, low energy and libido, general apathy and eventually muscle spasticity with hyperreflexia, incontinence and ataxia. It is caused by the virus itself rather than an opportunistic infection. Diagnosis is based on clinical probability

Answer 10

A – Cushing’s syndrome The features of Cushing’s syndrome are caused by raised levels of glucocorticoids from any source. Causes include steroid use (as in this case), ectopic ACTH secretion and a pituitary tumour (Cushing’s disease). In addition to the physical features (weight gain, hirsutism, striae, acne, plethora, bruising, thin skin, cataracts) psychological features include depression, insomnia, reduced libido and occasionally psychosis.

Answer 11

B – Generalized anxiety disorder Generalized anxiety disorder is defined as generalized, excessive worry for more than 6 months. It is twice as common in females and occurs frequently in early adulthood. Sufferers of generalized anxiety disorder feel anxious or nervous most of the time. There is not one particular trigger, and it can be described as ‘free-floating’. There is an underlying worry that ‘something bad may happen’. Physical symptoms include trembling, sweating, light-headedness, palpitations, dizziness, abdominal discomfort and muscle tension. Genetic predisposition overlaps with the predisposition to depression. Management options include psychological therapies, selective serotonin reuptake inhibitors (SSRIs), benzodiazepines for rapid anxiolysis and b-blockers for autonomic symptoms. The disease course is usually chronic and fluctuating. Panic disorder is characterized by sudden-onset, severe panic attacks that are not limited to one particular situation. Panic attacks last a few minutes and are often accompanied by a fear of going mad or dying. Physical symptoms include nausea, hyperventilation, palpitations, chest pain, sweating and light-headedness. Affected people are symptom-free in between attacks. Panic disorder is only diagnosed if there is no underlying disorder such as depression. First-line management is with cognitive behavioural therapy. Panic disorder is most common in young female adults.

Answer 12

B – Disorganized speech and behaviour and flat affect Key symptoms of hebephrenic schizophrenia are disorganized speech and behaviour and flat or inappropriate affect. It has an earlier age of onset and a worse prognosis than the paranoid type. In paranoid schizophrenia there are predominantly positive symptoms (delusions and hallucinations) with an increased suicide risk. Paranoid schizophrenia has the best prognosis. Simple schizophrenia is a gradual decline in functioning. There are negative symptoms without positive symptoms. Chronic schizophrenia can be diagnosed if negative symptoms persist one year after positive symptoms. In delusional disorder, it is delusions alone that make up the clinical picture, although very occasional and transient hallucinations do not exclude the diagnosis. It usually starts in middle age. Transient psychotic disorder usually reaches a crescendo of symptoms within 2 weeks with complete resolution within 3 months. It may be precipitated by a stressful life event. Catatonic schizophrenia has a prominence of catatonic symptoms. These are stupor, excitement, posturing, negativism, rigidity, waxy flexibility, perseveration of words and mutism.

Answer 13

A – Anankastic People with anankastic personality disorder frequently display an inflexible preoccupation with rules, order and attention to detail (almost like an obsessive– compulsive). They may be very cautious and stubborn, and may try to enforce their ways on others. Anxious (avoidant) personality disorder is characterized by a tendency to worry, extreme anxiety, feelings of inferiority and a fear of criticism/disapproval to the point of avoiding people/situations where this might happen. Dependent personality types are often passive, relying on others to make decisions. They fear abandonment and find it difficult to cope with daily chores. Such personalities may excessively give priority to the needs and wishes of others, over their own, in an attempt to maintain their close relationships

Answer 14

B – Flight of ideas Flight of ideas is accelerated thoughts with abrupt incidental changes of subject and no central direction. The connections between topics are based on chance relationships, such as rhyming words or alliteration. Schneider’s three features of normal thought are constancy, organization and consistency. There are five features of Schneider’s formal thought disorder. These are: † Derailment ! a thought derails on to a subsidiary thought † Drivelling ! a disordered intermixture of constituent parts of a thought † Fusion ! heterogeneous thoughts are interwoven with each other † Omission ! part of a thought is omitted † Substitution ! a major thought is substituted with a subsidiary thought A delusion is a belief held with absolute conviction, such that it is not changeable, even by compelling counterargument or proof to the contrary. A primary delusion has no obvious cause considering the patient’s circumstances. Secondary delusions are more closely linked with the rest of the clinical picture, for example grandiose delusions (which is the belief of inflated self worth) are common in mania, and a persecutory delusion may be seen in paranoid schizophrenia. A bizarre delusion is one which would be seen as totally implausible within the patient’s culture. An overvalued idea is an unreasonable, sustained, intense preoccupation that is maintained with less than delusional intensity, i.e. the patient may accept that it might not be true. An obsession is a repetitive senseless thought which is recognized as irrational but is unsuccessfully resisted by the person. The motor equivalent of an obsessional thought is a compulsion – a repetitive, stereotyped, seemingly purposeful behaviour which is not actually useful and is recognized as such by the patient. Ideas of reference are thoughts that the events or objects in one’s immediate environment have a particular or unusual significance. Monomania is the pathological preoccupation with a single subject, and egomania is the pathological preoccupation with oneself.

Answer 15

C – Normal behaviour Although this behaviour may be seen as eccentric, there is nothing in the history that suggests an underlying psychiatric disorder

Answer 16

B – Delusions of poverty The three core symptoms of depression are low mood, anhedonia (loss of pleasure) and anergia (low energy). The diagnostic criteria require there to be a history of two out of three core symptoms for at least 2 weeks. In addition, there should be at least two of the following seven symptoms: † Decreased concentration † Reduced self-esteem † Guilt † Pessimism about the future † Self-harm ideation † Disturbed sleep † Reduced appetite The severity of depression is classified as mild (4 symptoms in total), moderate (5–6 symptoms in total), and severe (7 symptoms in total, including all 3 core symptoms). Beck’s cognitive triad describes types of negative thought that occur in depression. They are a negative view of oneself, a negative view of the world and a negative view of the future

Answer 17

D – Sadism Sadism and masochism are forms of paraphilia. Sadism involves pleasure from inflicting pain or humiliating someone. Masochism involves gaining sexual excitement from having pain or humiliation inflicted on oneself. Sadomasochism is a term comprising both sadism and masochism Sadism, from the French novelist Marquis de Sade, whose writings describe it. Masochism, from the Austrian writer Leopold von Sacher-Masoch, whose stories describe it.

Answer 18

E – Serotonin syndrome This lady has recently started taking opioids (tramadol). The combination of opioids with selective serotonin reuptake inhibitors (fluoxetine in this case) is associated with the development of serotonin syndrome. Signs include severe hypertension, tachycardia, high pyrexia, myoclonus, sweating and hyperreflexia. Managementis initially symptomatic followed by removal of the offending drugs. Other drugs that may contribute to the serotonin syndrome include other antidepressants (monoamine oxidase inhibitors, triptans, herbs (St John’s wort, ginseng), stimulants (cocaine, amphetamines), lithium and metoclopramide

Answer 19

A – Night terrors Night terrors are seen in children, affecting 6% of 4 to 12-year-olds, and resolve by adolescence. The child usually awakes suddenly during the first third of the night in a state of panic and fearfulness. There are associated autonomic responses, e.g. tachycardia and dilated pupils. Affected children are not easily comforted but, when they fully awake (usually the next morning), they have no recollection of the event. Nightmares are frightening dreams in which the individual awakes suddenly and is then fully alert and can remember the dream very well. They usually occur during the second half of the night. Nightmares affect up to 50% of adults occasionally while 3 to 5-year-olds are more likely to experience repeated nightmares. Non-organic disorder of the sleep–wake cycle is caused by a lack of synchrony with the desired sleep–wake pattern. The problem is often perceived as either insomnia or hypersomnia. Management is by attention to sleep hygiene.

Answer 20

E – Perseveration In perseveration, mental operations are continued beyond when they are relevant. It is highly suggestive of organic brain disease. Examples are palilalia, which is repeating a whole word e.g. ‘knife . . . knife . . . knife . . . ’ and logoclonia, which is repeating the last syllable of a word e.g. ‘pass the yorkshire pudding . . . ding . . . ding . . . ding’. Word salad or schizophasia is an incomprehensible mishmash of words and phrases. Dysprosody is loss of the normal melody of speech. Logorrhoea describes fluent, rambling speech – an extreme version of verbal diarrhoea! A neologism is a new word, or an old word, used in a new way. Expressive aphasia is a difficulty verbalizing thoughts, although comprehension is intact. It is seen in patients after a stroke. In receptive aphasia, there is difficulty understanding, and although the patient feels they are speaking fluently, it is not usually possible to make out any words in their voice. In global aphasia, both expressive and receptive aphasias are present. Dysarthria is the physical difficulty in controlling movements of the mouth in order to articulate the words. Mutism is the complete loss of speech. Poverty of speech is reduced/restricted speech, e.g. monosyllabic answers. Pressure of speech is increased quality and rate of speech. Stammering is when the flow of speech is broken by pauses and repetition. Echolalia is the imitation of another person (even if it is in a foreign language). Coprolalia is the explosive exclamation of obscenities, seen in Tourette’s syndrome. The following forms of speech give the examiner insight into the form of the patient’s thoughts. Knight’s move thinking is demonstrated when speech jumps from one subject to another with no link. Flight of ideas is accelerated thoughts with abrupt incidental changes of subject and no central direction

Answer 21

B – Opiate use This man is likely to be suffering the effects of opiate use. Examples of opiates include morphine, heroin, methadone and codeine. Effects of opiates (in addition to analgesia) include euphoria, nausea and vomiting, constipation, anorexia, hypotension, respiratory depression, tremor, pinpoint pupils and erectile dysfunction. The treatment of overdose (after A-B-C) is with the antidote naloxone. This is ideally given intravenously (but can be given intramuscularly or by inhalation). An infusion of naloxone may be necessary as the half-life is short. The effects of opiate withdrawal can be very extreme. They include dilated pupils, lacrimation, sweating, diarrhoea, insomnia, tachycardia, abdominal cramp-like pains, nausea and vomiting.

Answer 22

D – Transsexualism Transsexualism, a gender identity disorder, is the persistent desire to live and be accepted as a member of the opposite sex. There is a feeling that the physical body is inconsistent with the sense of self. There may be a desire to have surgery or hormonal treatment in order to change it. Dual role transvestism is the intermittent desire to dress as the opposite sex that is not for the purpose of arousal, or for any permanent change. The male to female ratio is approximately 3:1. Management is usually by specialists, and surgery/hormone treatments can be done although the long-term outcome is uncertain. There is usually a requirement to live as the opposite sex for a year before starting treatment.

Answer 23

A – Cotard’s syndrome Cotard’s syndrome is a nihilistic delusion that one is dead, has lost all their possessions, does not exist or is decaying, etc. It can be a feature of severe depression. Ekbom’s syndrome is a delusional psychosis that one is infected with parasites. It may be accompanied by a physical sensation of parasites crawling around or burrowing into the skin (formication).

Answer 24

B – 1% Suicide is important to consider because it is one of the most extreme negative outcomes in psychiatry. It is important to know the risk factors in order to identify and manage those at risk. Discussing suicidal ideation with a patient does not increase their risk of suicide (as is sometimes feared). Risk factors for suicide include: † Male sex † Age .45 years † Being divorced, single or widowed † Unemployed † Social classes I and V † Psychiatric illness † Previous episodes of self-harm † Chronic physical illness † Recent adverse life events Protective factors include having children and being religious. In populations, the rate of suicide increases in summer months and decreases during times of war. The annual incidence of suicide is 1 in 10,000. After an act of self-harm the risk of completed suicide within the next year is 1%, i.e. 100 times more that the risk in the general population. The following features of self-harm are indicators of strong suicidal intent: a more violent/dangerous action, careful planning and preparation, making precautions to avoid being discovered, failing to seek help afterwards and final acts (such as making a suicide note or a will). It should be ascertained whether or not they intended to die at the time and, if so, what their reaction is to still being alive (do they regret being alive and still wish to die?). There is a high rate of recurrence in people who self-harm.

Answer 25

D – 72 hours Section 4 allows an emergency admission to hospital when there is not enough time to organize a Section 2. Its duration is 72 hours and there is no right of appeal against it. It can be arranged by one doctor and the Approved Social Worker. This allows time for a Section 2 or 3 to be sought. Section 4 orders are not commonly used.

Answer 26

C – Piblokto Piblokto is described in Inuit women living within the Arctic Circle. There is sudden-onset hysteria (screaming, crying, etc.) and bizarre behaviour. This may include removal of clothes, coprophagia (ingestion of faeces) and violence. Attacks last a couple of hours and there is often amnesia after the event. It is thought that piblokto may be related to vitamin A toxicity, as the native Eskimo provides large quantities of it. Windigo is recognized in native North American tribes. Affected people believe that their body is possessed with a spirit that craves human flesh. This results in obsessive thoughts and compulsions regarding violence and cannibalism