Psych Flashcards
1
Q
Depression ICD-10
A
Must last at least 2 weeks and represent a change from normal
Must not be secondary to other causes, i.e. drugs, alcohol misuses, medication etc
Core sx:
- low mood
- anhedonia
- anergia
Other sx:
- sleep disturbance
- diminished appetite
- reduced concentration and attention
- reduced self-esteem/sel-confidence
- ideas of guilt and worthlessness
- bleak and pessimistic views of future
- ideas or acts of self harm/suicide
2
Q
Psychotic sx in depression
A
Delusions
- mood congruent, nihilistic
- overbearing guilt for misdeeds, responsible for world events
- deserving of punishment
Hallucinations
- 2nd person auditory most common
- olfactory bad smells, rotting flesh
- visual, demons, dead bodies
3
Q
Severity of depression levels
A
Mild: 2 core sx + 2 other sx
Moderate: 2 core sx + 3+ other sx
Severe: 3 core sx + 4+ other sx
Severe w/ psychosis: severe depression + psychotic sx (delusions +/- hallucinations)
4
Q
Tx of mild-to-moderate depression
A
Consider watchful waiting, assessing again normally within 2 weeks
Consider offering one or more low-intensity psychosocial interventions
- CBT (self-guided, computerised)
- Relaxation therapy
- Brief psychological interventions (brief CBT, counselling, 6-8 sessions)
ANTI-DEPRESSANTS NOT RECOMMENDED**
5
Q
Tx of moderate-to-severe depression
A
Check if at risk
- urgent psych referral if pt has active suicide ideas/plans or putting themselves or others at immediate risk
Offer anti-depressant medication COMBINED with high-intensity psychological treatment (CBT or IPT; 1:1)
ECT
6
Q
Factors necessitating admission
A
Self neglect Risk of suicide/self harm Risk to others Poor social support Psychotic sx Lack on insight Tx resistant depression
7
Q
Dysthmia
A
Presence of chronic low grade depressive sx (usually long-standing)
Always slightly depressed, it’s become their baseline
Mild sx of depression that lasts a long time, 2:1 F:M, 25% suffer chronic sx
8
Q
Postnatal depression
A
10-15% women within 1-6 months post partum
Peak incidence is 3-4 weeks post-partum
9
Q
Seasonal affective disorder
A
Low mood w change in season
Lack of sunlight -> lack of pineal gland melatonin synthesis -> lack of serotonin
Light therapy + anti-depressant tx
10
Q
Bipolar affective disorder ICD-10
A
Pt must experience ‘at least two episodes one of which must be hypomanic/manic or mixed, with recovery usually complete between the episodes’
Depressive episode same as unipolar depression
Criteria for hypomanic/manic episodes being the same as unipolar hypomania/mania
**Mixed affective episodes is when there is occurrence of both hypomanic/manic and depressive sx in single episode present everyday for at least 2 weeks
(almost a retrospective diagnosis)
11
Q
BPAD epidemiology
A
BPAD 1 - 1%, mean onset 18.2
BPAD 2 - 1.1%, mean onset 20
Suicide rate is x15-18 higher than general population
10% pts who begin with depressive episode go onto develop episode of mania within 10 years
- genetic disposition
- greater incidence in upper social classes
- no differences in sexes/ethnicities
12
Q
Manic episode ICD-10
A
Mood
- predominately elevated, expansive, irritable, definitely abnormal for individual
- mood must be prominent and sustained for at least 1 week (unless severe enough for hospital admission)
At least 3 of following signs must be present (4 is only irritable), leading to severe interference w personal functioning in daily living:
- increased activity/physical restlessness
- increased talkativeness (pressured speech)
- flight of ideas or subjective experience of thoughts racing
- loss of normal social inhibitions
- decreased need for sleep
- inflated self-esteem/grandiosity
- distractibility/constant changes in plans
- recklessness behaviour (spending sprees, foolish enterprises, reckless driving)
- marked sexual energy/sexual indiscretions
13
Q
Psychotic sx of mania
A
Delusions
- grandiose (religious figure, special powers)
- persecutory (suspicion develops)
Incomprehensible speech
- pressured speech
Self neglect
Cationic behaviour
- manic stupor
14
Q
Hypomanic episode ICD-10
A
Mood elevated or irritable to a degree abnormal for inidividual and sustained for at least 4 consecutive days
Same 3 signs as manic episode need to be bresent
15
Q
Mania vs hypomania
A
Degree of functional impairment: hospitalisation is proxy of functional deterioration
DSM: duration criteria of 4 days for hypomania and 7 days for mania in DSM is arbitrary; follow-up studies show most hypomanic episodes in BPAD 2 lasts for less than 4 days
16
Q
Beck’s Cognitive Triad
A
Self - Future - Worth
Worthless guilt - Helplessness - Hopelessness
=> Informs CBT
17
Q
Cotard syndrome
A
Rare subtype of nihilistic delusions
Pt believes they or part of them is dead or does not exist
Seen most commonly in severe depression, but is also associated with schizophrenia
18
Q
SSRI action
A
Selective serotonin reuptake inhibitors
fluoxetine, setraline
Side effect: headache, GI (nausea, diarrhoea/constipation), sleep disturbance/vivid dreams, sexual dysfunction
19
Q
TCA action
A
5-HT and NA re-uptake inhibition; affects multiple transmitters though (also anti-cholinergic/muscarinic effect - very dirty x )
- prescribed when pts don’t respond to first-line
- Amitryptyline, clomipramine, lofepramine*
Just as effective as SSRIs if not for side effect profile; lethal in over dose
20
Q
MAOI action
A
Increase availability of 5-HT and NA in synapse
- irreversible old ones: phenelzine, tranylcypromine, isocarboxazid*
- reversible: moclobemide*
21
Q
SSRI consultation
- what do you need to tell the pt?
A
‘blocks the serotonin pumps’
Common side effects
Drug cx: hyponatraemia, GI bleeding
Serotonin syndrome: psych sx, neuro sx including myoclonus and autonomic sx
Discontinuation syndrome (short half-life): flu-like illness, trouble sleeping, shocks, anxiety
Suicidality: potential association (small evidence in adolescence), general pragmatic view warn all pts potential to feel suicidal
Duration: same dose for 6-12 months min. when in remission and 2 years for those at greater risk of relapse
Review: 2 weekly initially and then regularly thereafter
22
Q
MAOI problem
A
Tyramine interaction (cheese effect)
- pts need special low tyramine diet
- avoid cheese, cured meat, fermented pickles, red wine, soybeans etc
Tyramine amine derivative of tyrosine AA, has sympathomimetic effect (release of A from adrenal glands)
Hypertensive episode!!!
- tachycardic, flushing, severe throbbing headache, pallor, stroke, death, renal failure
23
Q
Mirtazepine action
A
NaSSA; blocks presynaptic alpha-2 adrenergic receptors
Autoreceptor hence less feedback and more NA release
Side effects: drowsiness, increased appetite, weight gain
**used a lot in old age pysch
24
Q
Venlafaxine/duloxetine action
A
SNRI; similar to SSRI incl. side effect profile
Pts require monitoring of BP
25
Trazadone action
Used in old age psych
Side effects: sedation, arrhythmia, hypotension, priapism
26
Vortioxetine action
Serotonergic modulator
New and expensive
Improves cognitive function
27
St John's Wort
Not recommended as uncertain about appropriate doses and potential serious interactions with other drugs
Not as effective or safe as SSRI medication so not used in UK
*fucks up P540 cytochrome
28
EPSE - what are they and when can they occur?
```
Extrapyramidal side effects of antipsychotics:
Dystonia (early, within hours)
Akathisia (hours to weeks)
Parkinsonism (days to weeks)
Tardive dyskinesia (months or years)
```
29
Dystonia sx and tx (EPSE)
sx: involuntary painful, sustained muscle spasm
tx: anticholinergics (e.g. procyclidine)
30
Akathisia sx and tx (EPSE)
sx: unpleasant subjective feeling of restlessness; pts have to pace about and jiggle their legs to cope w it
tx: decrease dose/change antipscyhotic, add propranolol or benzodiazepines
31
Parkinsonism sx and tx (EPSE)
sx: triad of resting tremor, rigidity (like stiffness), bradykinesia, pts may have mask-like faces and shuffling gait
tx: decrease dose/change antipsychotic, try anticholinergic (i.e. procyclidine) but review frequently
32
Tardive dyskinesia sx and tx (EPSE)
sx: rhythmic involuntary movements of mouth, face, limbs, and trunk which are v distressing, pts may grimace or make chewing/sucking movements w their mouth and tongue
tx: stop antipsychotic or reduce dose, avoid anticholinergics as this worsens problem, switch to atypical/clozapine
often irreversible :(
33
3 core components of psychosis
Perceptions => hallucinations
Beliefs => delusions
Functioning => loss of insight
34
Ddx of schizophrenia (ICD-10 definitions)
Paranoid: dominated by relatively stable delusions, usally w auditory hallucinations
Catatonic: prominent psychomotor disturbances (hyperkinetic/stupor)
Residual: chronic; negative sx dominate w poor self-care and social performance
Persistent delusional disorder: single/set of related delusions in ABSENCE of auditory hallucinations, delusions of control, blunting of affect, and brain disease
Acute and transient psychotic disorders: acute onset of psychotic sx, delusions hallucinations disrupt ordinary behavior within <2 weeks, complete recovery occurs within days to months, associated w acute stress
35
Schneider's First-Rank Sx
Auditory hallucinations
- third person, running commentary, thoughts spoken aloud
Passivity experiences
- delusions of control (made feelings, impulses)
Thought withdrawal
- thoughts taken out of head
Though insertion
- thoughts inserted into head
Delusional perception
- linking normal perception to a bizarre conclusion (i.e. see red car -> have 2 souls)
36
Negative sx in schizophrenia
```
Social withdrawal
Reduced affect
Apathy
Anhedonia
Defects in attention control
```
37
Hypnagogic vs hypnopompic hallucinations
Hallucinations when falling asleep
Hallucinations when waking up
- drug use, medication, anxiety, personality disorders
38
Mx of schizophrenia and related psychoses
Medication
(typical + atypical antipsychotics)
CBT for psychosis
```
Family interventions
(high expressed emotion associated w increased relapse)
```
Psychosocial rehabilitation (care coordination, assertive outreach, EIS, recovery)
Physical health of people w psychosis
39
General antipsychotic action
Dopamine receptor antagonists
40
How does aripiprazole work?
Partial dopamine agonist
41
Typical vs atypical antipsychotics side effects
Typical
- greater risk of EPSE and cardiac risk
Atypical
- greater risk of metabolic syndrome and cardio/cerebrovascular risk
42
Dopamine theory of schizophrenia (4 pathways)
Mesolimbic pathway
- excessive activity causes psychosis (pathway targeted by antipsychotic medication)
Mesocortical pathway
- under activity causes the negative syndrome and cognitive impairment (harder to target by medication)
Nigrostriatal pathway
- under activity causes Parkinsonism (EPSEs seen by antipsychotic medication)
Tuberoinfundibular pathway
- antipsychotics cause under activity thus less inhibition of prolactin, leading to hyperprolactinaemia
43
Relevance of the QTc interval?
Normal interval:
<440 ms in men, <470ms in women
All antipsychotics can prolong QTc interval
Potential to develop torsades de point -> VT -> death
Must have ECG prior to commencing medication
44
Why should you monitor BMI, BP, waist circumference, HbA1c, lipids, LFTs when on antipsychotics?
Metabolic syndrome is a side effect, particularly atypical antipsychotic
Olanzapine*** biggest cause
Iatrogenic cause of central obesity, bad as schizophrenia already increased risk of CVD problems
45
When is clozapine indicated?
For treatment resistance schizophrenia (when at least 2 antipsychotic drugs have failed, at least 1 should be atypical, for at least 6 weeks)
SE:
- Risk of agranulocytosis -> regular FBC testing ****
46
What do you see in neuroleptic malignant syndrome?
Mental status change
- confusion, reduced GCS
Muscular rigidity
- severe 'lead pipe' rigidity
Hyperthermia
Autonomic instability
- tachycardia, sweating, hypertensive, tremor
Typically occurs in men, high dose antipsychotic usage, past history NMS, dehydrated
47
What pathology is seen in neuroleptic malignant syndrome?
Dopaminergic blockade leads to extreme muscle rigidity -> rhabdomyolysis -> acute renal failure
Depletion dopamine in hypothalamus -> elevated temperature
48
Ix for neuroleptic malignant syndrome
```
Elevated CK
Raised WCC
Reduced renal function
Raised hepatic transaminase
Metabolic acidosis
```
49
Mx for neuroleptic malignant syndrome
ABCDE
Transfer to A&E
Stop all antipsychotics
Supportive: IV fluids, antipyretics/cooling devices, dialysis
Potential tx: muscle relaxant, dopaminergic replacements, ECT
50
NMS vs SS
Both are rare and potentially lethal
Both present w altered consciousness, neuromuscular status and autonomic dysfunction
Both treated w ABCDE approach and supportive measures
NMS
- lack of dopamine
- sx PLUS lead pipe rigidity
- develops over time
- tx: raise dopamine (bromocriptine, ECT)
SS
- excessive serotonin
- sx PLUS myoclonus, tremor, hyperreflexia (less rigidity)
- acute timeframe
- tx: serotonin antagonist effect (cyproheptamine)
51
Delirium tremens presentation
Within 48hrs of abstinence, lasts 3-4 days
Confused, hallucinations (visual), fearful, gross tremor of hands, delusions, autonomic disturbance (sweating, tachycardia, hypertension, dilated pupils, fever)
52
Delirium tremens tx
Medical emergency
Reducing benzodiazepine regime and parenteral thiamine
Manage potential fatal dehydration and electrolyte abnormalities
53
Wernicke's vs Korsakoff's
Wernicke's encephalopathy
- acute thiamine (b1) deficiency
- classic triad of confusion, ataxia, and ophthalmoplegia
- medical emergency as if untreated it progress to...
Korsakoff's syndrome
- IRREVERSIBLE anterograde amnesia (some retrograde); registers new events but cannot recall within minutes
- patients may CONFABULATE to fill in gaps in their memory
54
Complications of IV drug use
Local
- abscess
- cellulitis
- DVT; repeated injection into femoral veins damages valves, slows down venous return
- emboli
Systemic
- septicaemia
- infective endocarditis
- blood-borne infections
- increased risk of overdose; less dose-titration than in smoking
55
What does naloxone do?
Opiate antagonist
- antidote for opiate overdose
- beware; pts plunge into immediate withdrawal
56
What does naltrexone do?
Opiate antagonist
- blocks opiate receptors and thus euphoric effects of opiates
- given to people who have completed opiate detoxification as a relapse prevention agent
57
CAGE screening questionnaire
C "Have you ever felt you should CUT DOWN on your drinking?"
A "Have people ANNOYED you by criticizing your drinking?"
G "Have you ever felt GUILTY about your drinking?"
E "Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?" (EYE-OPENER)
58
What are the limit ages for the following developmental milestones?
a) Eye contact
b) Turns to a voice
c) Walks independently
d) First word
(average age)
a) 3 months (1-4 weeks)
b) 9 months (7 months)
c) 18 months (11-13 months)
d) 2 years (8-18 months)
59
What is agoraphobia?
Fear of being in situations where escape might be difficult or that help wouldn't be available if things go wrong
60
What is the gold standard mood stabiliser?
Lithium carbonate
61
What can lithium be used for?
BPAD
Schizoaffective disorders
Depression (recurrent/tx-resistant)
62
What is the therapeutic range of lithium like?
Narrow therapeutic range
0. 4-1mmol/L
- needs to be monitored to ensure not sub-clinical/toxic dose
63
What teratogenic impact may lithium have?
Ebstein's anomaly
64
What may lithium toxicity present with?
- Coarse tremor
- Marked GI upset
- Ataxia
- Dysarthria
- Impaired consciousness
- Epileptic seizures
- Nystagmus
- Renal failure
65
What are possible complications of lithium use?
- Renal disease (diabetes insipidus, CKD)
- Hypothyroidism
- Wt gain
- Persistent tremor
- T wave flattening on ECG
- Lethargy
- Mild cognitive impairment
- Mild leucocytosis
66
Ix to do before starting lithium
FBC, U&Es, Calcium, TFTs, ECG (if known cardiac disease)
67
How often do lithium pts get monitored?
Initialy weekly tests
Once stable, every 3 months U&Es, eGFR, 12hr-serum lithium, TFT
Reduced to 6 months for lower risk pts after a year
68
What drugs should pts on lithium be careful of using?
NSAIDs
| ACEi
69
What rash do you need to be aware of when using lamotrigine/carbamazepine?
Steven-Johnsons syndrome
70
Which antidepressant is often used with bipolar depression alongside other tx?
Fluoxetine
71
What are the following called?
a) pt feigning sx for external gain
b) pt feigning sx for unconscious reasons
c) pt w sx unexplained by investigation findings
a) Malingering
b) Munchausen's syndrome (factitious disorder)
c) Functional symptoms (have no known structural cause)
72
What is conversion disorder?
Neurological deficit that is not explained by structural disorder
- blind, paralysis, deaf
- result of ongoing psychosocial stress
73
What are the three domains that are affected in ASD?
1. Reciprocal social interaction
2. Communication abnormalities
3. Restricted behaviours and routine
74
ICD-10 says ASD develops in what aged children?
Abnormal/impaired development manifests before the age of three
75
What is Rett syndrome?
Condition in girls where normal early development followed by partial/complete impact on:
- speech
- skills in locomotion
- use of hands
- deceleration in head growth
Onset is between 7-24 months
76
12 month old girl presents with loss of purposive hand movements, hand-wringing stereotypes, and hyperventilation - what is this and its prognosis?
Rett syndrome
Poor prognosis
- social and play development arrested
- social interest maintained
- severe mental retardation invariably results
77
7 yr old girl is complaining about headaches for last 3 months, and her teachers have flagged up to her foster carer that she has been underperforming in lessons and talking back to teachers.
It is noted in her GP notes she is in foster care as her parents were deemed unfit to care for her.
What treatment may you consider?
?Depression
Take separate hx w child without guardian present to pick up on potential safeguarding issues
1st line CBT for depression in children
Severe cases, refer to CAMHS to consider fluoxetine (>/= 8yo)
78
School refusal vs truancy
School refusal
- anxiety based, unconcealed absence from school
- children find difficult going/staying in school
- child typically has tummy ache before school but never on weekends/holiday
Truancy
- illegal/illegitimate absence from school
- unexcused absence without parental permission
- potentially seen in CD/ODD
79
How long should there be a history of antisocial behaviour to diagnose Conduct Disorder?
6 months+
80
What is a tic?
Involuntary, rapid, recurrent, nonrhythmic motot movement or vocal production that is of a sudden onset and serves no apparent purpose
81
What is coprolalia?
Vocal tic where person uses socially unacceptable (often obscene) words
82
What characterises learning disabilites?
Global impairment of intelligence and significant difficulties in socially adaptive functioning
83
How is LD graded in the ICD-10?
```
IQ levels:
Mild = 50-69
Moderate = 35-49
Severe = 20-34
Profound = <20
```
84
Name 3 syndromes associated with LD
1. Down syndrome
2. Fragile X
3. Fetal alcohol syndrome
85
What approach may be taken in Behavioural Therapy?
ABC:
Antecedents - avoid
Behaviour - reinforce positive behaviours, prevent reinforcing negative behaviours
Consequences - help people understand consequences of their actions
86
What is diagnostic overshadowing?
Tendency to attribute everything to pt's mental health condition when such sx suggest a comorbid condition
In context of LD, for example, changes in behaviour, mental state, or ability are dismissed, despite usually indicating physical or mental illness in people without a LD
87
What is the criteria for diagnosis of personality disorder in ICD-10?
```
REPORT
R elationships affected
E nduring
P ervasive
O nset in childhood/adolescence
R esult in distress
T rouble in occupational/social performance
```
88
What are considered 'Cluster A' personality disorders?
'Odd or eccentric'
- paranoid
- schizoid
89
What are considered 'Cluster B' personality disorders?
'Dramatic, erratic, or emotional'
- histrionic
- emotionally unstable
- dissocial
90
What are considered 'Cluster C' personality disorders?
'Anxious and fearful'
- anankastic
- anxious (avoidant)
- dependent
91
Features of paranoid personality disorder and other possible ddx
```
SUSPECT
S ensitive
U nforgiving
S uspicious
P ossessive and jealous of partners
E xcessive self-importance
C onspiracy theories
T enacious sense of rights
```
ddx: schizophrenia, persistent delusional disorder
92
Features of schizoid personality disorder and other possible ddx
```
ALL ALONE
A nhedonic
L imited emotional range
L ittle sexual interest
A pparent indifference to praise/criticism
L acks close relationships
O ne-player activities
N ormal social conventions ignored
E xcessive fantasy world
```
ddx: ASD, agoraphobia, social phobia, psychosis, depression
93
Features of histrionic personality disorder and other possible ddx
```
ACTORS
A ttention seeking
C oncerned with own appearance
T heatrical
O pen to suggestion
R acy and seductive
S hallow affect
```
ddx: hypomanic/manic episode, substance misuse
94
Features of both subtypes of unstable personality disorder
```
AEIOU
A ffective instability
E xplosive behaviour
I mpulsive
O utbursts of anger
U nable to plan or consider consequences
```
95
Features of borderline EUPD and other possible ddx
```
SCARS
S elf-image unclear
C hronic 'empty' feelings
A bandonment fears
R elationships are intense and unstable
S uicide attempts and self-harm
```
ddx: adjustment disoder, depression, pyschosis
96
Features of impulsive EUPD and other possible ddx
```
LOSE IT
L acks impulse control
O utbursts or threats of violence
S ensitivity to being thwarted or criticised
E motional instability
I nability to plan ahead
T houghtless of consequences
```
ddx: affective disorder, adjustment disorder, adult ADHD
97
Features of dissocial (antisocial) personality disorder and other possible ddx
```
FIGHTS
F orms but cannot maintain relationships
I rresponsible
G uitless
H eartless
T emper easily lost
S omeone else's fault
```
ddx: acute psychotic episode, manic episode
98
Features of anankastic personality disorder and other possible ddx
```
DETAILED
D oubtful
E xcessive detail
T asks not completed
A dheres to rules
I nflexible
L ikes own way
E xcludes pleasure and relationships
D ominated by intrusive thoughts
```
ddx: obsessive-compulsive disorder, ASD
99
Features of anxious (avoidant) personality disorder and other possible ddx
```
AFRAID
A voids social contact
F ears rejection/criticism
R estricted lifestyle
A pprehensive
I nferiority
D oesn't get involved unless sure of acceptance
```
ddx: social phobia, ASD, schizophrenia, depression
100
Features of dependent personality disorder and other possible ddx
```
SUFFER
S ubordinate
U ndemanding
F eels helpless when alone
F ears abondonment
E ncourages others to make decisions
R eassurance needed
```
ddx: reliance on others because of cognitive impairment, anxiety disorder
101
What is the role of the following area of the brain?
a) Primary motor cortex
b) Primary somatosensory cortex
c) Supplementary motor cortex
d) Wernicke's area
e) Broca's area
a) Contralateral movement
b) Perception of contralateral somatosensory stimuli
c) Organisation of complex movement
d) Comprehension of speech
e) Expression of speech
102
Which lobe of the brain has been affected?
a) Auditory hallucinations
b) Visual agnosia
c) Contralateral spastic hemiparesis
d) Contralateral sensory impairment
a) Temporal
b) Occipital
c) Frontal
d) Parietal
103
Where are Wernicke's and Broca's area and how may a pt present if they are damaged?
Wernicke's
- temporal
- receptive dysphasia
Broca's
- frontal (dominant lobe)
- expressive dysphasia
104
Causes of delirium
```
PINCH ME
P ain
I nfection
C onstipation
H ydration
M edication
E nvironment
```
105
Delirium vs Dementia
Delirium
- sudden, fluctuating course
- shorter duration, <6 months
- impaired consciousness
- poor attention
- disorganised thinking, delusions + hallucinations common
- recovery once underlying cause treated
Dementia
- gradual, slowly progressive course
- lifelong, >6 months
- normal consciousness + attention
- impoverished thinking
- delusions + hallucinations possible later in illness
- deterioration likely
106
What are the acronyms that go with the following personality disorders to help remember the features of them?
a) Paranoid
b) Schizoid
c) Histrionic
d) EUPD
e) Dissocial
f) Anankastic/obsessive-compulsive
g) Anxious/avoidant
h) Dependent
a) SUSPECT
b) ALL ALONE
c) ACTORS
d) AEIOU (borderline: SCARS, impulsive: LOSE IT)
e) FIGHTS
f) DETAILED
g) AFRAID
h) SUFFER
107
Indicators of LD
Reports of difficulty in reading and writing
Difficulty in achieving skills (academic/daily life skills)
Attendance at specialist school
Special Education need statement
Experience of having to modify communication
Previously known to specialist children services
108
What is the classic sx triad in normal pressure hydrocephalus and why?
Dementia (subcortical) / Unsteady gait / Urinary incontinence
Due to distortion of periventricular white matter tracts
109
Amnesic syndrome
- what is it?
- most common cause?
- sx?
Characterised by profound anterograde memory loss - inability to lay down new memories from time of brain damage onwards
Most common cause: Korsakoff's
Sx: anterograde amnesia despite intact short-term memory (info lost once no longer used), confabulation, procedural memory intact
110
Domains that may be affected in frontal lobe syndrome
Executive dysfunction
- poor judgement, reasoning/problem-solving, planning/decision-making
Social behaviour and personality change
- loss of social awareness (irresponsible, inappropriate, disinhibited), impulsivity, euphoric or 'fatuous' mood; lability, repetitive/compulsive behaviours
Apathy
- lack of motivation and initiative, decline in self-care
111
Triad of PD
Tremor (pill-rolling type)
Rigidity (experienced as stiffness)
Bradykinesia (slowed movement)
112
What systemic illnesses should you consider in a pt presenting with depression?
```
Hypothyroidism
Corticosteroids
Hypo/hyperPTH
B12 deficiency
Hypo/hyperadrenalism
SLE
```
113
What systemic illnesses should you consider in a pt presenting with mania?
Hypothyroidism
Corticosteroids
Cushing's syndrome
114
What systemic illnesses should you consider in a pt presenting with anxiety?
Hyperthyroidism
Hypoglycaemia
Phaeochromocytoma
115
What systemic illnesses should you consider in a pt presenting with psychosis?
```
Corticosteroids
Acute porphyria
Cushing's syndrome
SLE
Hypothyroidism
```
116
What systemic illnesses should you consider in a pt presenting with dementia?
```
Hypothyroidism
B12 deficiency
Folate deficiency
Hypo/hyperPTH
Hypo/hyperadrenalism
```
117
Causes of a low MMSE score
```
Dementia
Delirium
Most psych illnesses (depression, anxiety, psychosis)
Learning disability
Sensory impairment
Language barrier
Feeling unwell, tired, irritable
```
118
Which mutations cause Alzheimer's and why?
AD gene mutations cause increased beta-amyloid
Presenilin 1 gene (chr 14)
Presenilin 2 gene (chr 1)
Beta-amyloid precursor protein (APP) gene (chr 21)
- likely why increased risk of AD in Down syndrome
119
What are the key elements of pathology in Alzheimer's?
Atrophy
- neuronal loss in hippocampus and later temporal and parietal lobes
Plague formation
- APP abnormally cleaved into beta-amyloid that aggregates into insoluble lumps
Intracellular neurofibrillary tangles
- made up of abnormal hyperphosphorylated tau proteins that accumulates in cell as insoluble paired helical filaments
Cholinergic loss
- pathways most affected in AD
120
4 A's of AD
Amnesia
- recent memories lost first, disorientation occurs early
Aphasia
- word-finding problems occurs; speech can become muddled and disjointed
Agnosia
- recognition problems
Apraxia
- inability to carry out skilled tasks despite normal motor function
121
What three sx in a clinical presentation of dementia would suggest dementia with Lewy bodies?
1. Fluctuating confusion w marked variation in levels of alertness
2. Vivid visual hallucinations (often of people or animals)
3. Spontaneous (new) parkinsonian signs
Would need 2/3 to alert you to potential DLB
122
What must you never prescribe to pts with dementia with Lewy bodies?
Anti-psychotics
| - extreme antipsychotic/neuroleptic sensitivity in DLB can result in death
123
Describe the following for Alzheimer's disease
a) histopath
b) onset
c) course
d) personality
Plaques and tangles, neuronal loss, particularly cholinergic
Insidious onset
Gradual decline
Eroded personality 'just not mum anymore', socially withdrawn
124
Describe the following for vascular dementia
a) histopath
b) onset
c) course
d) personality
Multiple cortical infarcts, arteriosclerosis
Sudden onset
Stepwise decline
Relatively preserved personality
125
Describe the following for dementia w Lewy bodies
a) histopath
b) onset
c) course
d) personality
Lewy bodies present
Onset varies
Gradual decline
More apathetic personality
126
Compare CT changes between AD, VD, and DLB
AD
- generalised atrophy, especially medial temporal and parietal
VD
- multiple lunencies, atrophy
DLB
- mild atrophy (less than AD)
127
Which antipsychotics should you avoid to treat behavioural sx in dementia?
Risperidone
Olanzapine
These increase the risk of stroke
128
Give examples of cholinesterase inhibitors
Donepezil
Galantamine
Rivastigmine
Reversible inhibitors of AChE
129
Common side effects of cholinesterase inhibitors
GI upset, agitation, fatigue, dizziness, muscle cramps, rash, headache
Bradycardia, seizures
AV/sino-atrial block, EXPSE sx, hepatitis
=> avoid/careful use in cardiac pts
130
What does memantine do?
Non-competitive glutamate receptor and antagonist
Recommended for moderate Alzheimer's disease or for pts contraindicated to AChE inhibitors
131
What medications should you avoid in delirium mx?
Avoid anticholinergics
132
What does Dr Warner never want to hear from an F1?
"the urine dip is clear so it's not delirium"
"we started abx three days ago and she is STILL confused"
"she is confused but fit for discharge"
133
Prescribing advice in older age patients
Check organ function (often lower dosing anyway)
Avoid polypharmacy where possible
Check for interactions
Advise pts before starting new drug of side effects/complications
Think falls, bleeds, arrhythmias, sedation, swallow, movement disorder etc
Decide duration of tx, only give as long as you need
==START LOW AND GO SLOW==
134
Pharm mx of AD
Mild-moderate
- AChEi
Moderate-severe
- memantine
135
Pharm mx of VD
Manage RFs
136
Pharm mx of DLB
Mild-moderate
| - AChEi
137
Mx of delirium on the ward
1. Behavioural mx techniques
2. Sensory stimulation
3. Risperidone
4. Olanzapine
5. Lorazepam
138
SLUDGE is an indication of what?
```
Salivation
Lacrimation
Urination
Defecation
GI distress
Emesis
```
Cholinergic crisis! Can result in resp distress
139
SAD PERSONS Score, what is it and what is it used for?
```
S ex: male
A ge: <19 or > 45 yo
D epression or hopelessness*
P revious attempts/psych care
E xcessive alcohol or drug use
R ational thinking loss*
S eparated/divorced/widowed
O rganised/serious attempt*
N o social supports
S tated future intent *
```
Each 1 point, * 2 points
Designed as assessment tool for screening suicide risk
0-4 = low
5-6 = medium
7-10 = high
(NOT to be used as replacement of full clinical examination)
140
Ddx to consider when suspected functional/somatisation disorders
Organic
- rule out any multisystem physical illnesses
Psych illnesses
- anxiety and depression (exacerbate sx)
- hypochondriasis (extreme healthy anxiety)
- schizophrenia, persistent delusional disorder (hypochondrial delusions and somatic hallucinations may occur)
Deliberate production of sx (RARE)
- factitious disorder (deliberate sx to receive medical tx; extreme cases are Munchausen's)
- malingering (faking sx for secondary gain)
141
What is the Reattribution Model?
Feeling understood
Changing the agenda
Making the link
Goldber's Reattribution Model to acknowledge pt concerns, bridge the psychological and physical gap in pt understanding of health, and make the explicit link between sx and pt's emotional state
142
What somatoform disorder are you considering below?
a) pt worried about persistent leg and eye pain, saying this is the onset of multiple sclerosis, keep asking for a 2nd opinion despite negative ix
b) recurrent physical sx lasted for two years, pt has had multiple referrals to different specialists and only negative ix, sx persist
c) pt attends A&E for 6th time that month complaining of severe abdo pain, always requesting stronger painkillers than paracetamol to help
a) Hypochondriasis
b) Somatisation disorder
c) Malingering
143
IQ range for learning disability categories according to ICD 10
Mild: 50-69
Moderate: 35-49
Severe: 20-34
Profound: below 20
144
When does alcohol withdrawal syndrome begin?
4-12 hours after the last drink
145
Alcohol withdrawal features
Coarse tremor, sweating, insomnia, tachycardia, nausea and vomiting, psychomotor agitation and generalised anxiety
Transitory visual hallucinations or auditory hallucinations may occasionally be present
146
Drug that reduces craving for alcohol
Acamprosate
147
Drug that reduces pleasure of drinking
Naltrexone
148
Drug used for aversion therapy by creating an unpleasant sensation in response to alcohol
Disulfiram
149
Important prescribing advice for elderly pts
Avoid polypharmacy
Check organ function (lower dosing usually)
Check with BNF/pharmacist/senior correct indication and no interactions
Think falls, bleeds, arrhythmia, sedation, swallow, movement disorder
Regular review
150
Which dementias would you use AChEIs for?
Mild-mod Alzheimer's
| Mild-mod Lewy body
151
Name AChEIs
Acetylcholinesterase inhibitors
- donepezil
- rivastigmine
- galantamine
152
Name a NMDA receptor antagonist
aka anti-glutamate
Memantine
153
When is memantine indicated?
Mod-severe Alzheimer's or those who cannot tolerate AChEi
154
Which of these is not useful for the assessment of the frontal lobe?
a) Similarities
b) Motor luria
c) Lexical fluency
d) Address recall
e) Go-No-Go
d) Address recall
The rest are all used for frontal assessment battery
- similarities (how are banana and orange alike)
- lexical (say as many words beginning with p)
- motor luria (copy motor sequency)
- go-no-go (tap when I tap twice, don't tap when I tap)
155
How can you manage a dementia patient that is becoming increasingly aggressive?
1. Behaviour mx techniques
2. Review and reduce sensory stimulation
3. Risperidone
4. Olanzapine
5. Lorazepam
156
Which drug should you avoid in elderly pts w dementia?
Benzo
- paradoxical effect
- worsen cognition, falls, breathing
- delirium
157
Which types of dementia should not use antipsychotics?
Lewy body
| Parkinson's
158
General principles of care for delirium patients
```
Single room, good lighting
Address sensory impairment
Familiar staff/family
Review need for meds
Ensure adequate nutrition, hydration, orientation (clocks/prompts)
Prevent constipation, retention
```
159
Stepped Care model for depression
Step 1
- assessment, active monitoring, support, psychoeducation, self-help
Step 2
- low level psychological interventions +/- meds
Step 3
- meds and high level psychological interventions
Step 4
- consider addition of ECT
160
Name SSRIs
```
Citalopram
Escitalopram
Sertraline
Fluoxetine
Paroxetine
```
161
Name SNRIs
Venlafaxine
| Duloxetine
162
Name NASSA
Mirtazapine
163
Name SARIs
Trazadone
164
Name MAOIs
Phenelzine
Tranylcypromine
Moclobemide
Isocarboxazid
165
Name TCAs
```
Clomipramine
Imipramine
Amitriptyline
Nortriptyline
Dothiepin (dosulepin)
```
166
What type of drug is vortioxetine?
Mixed 5HT agonist and antagonist
167
What type of drug is agomelatine?
M1 and M2 melatonin receptor agonist
168
Common SSRI adverse effects
N&V
Sexual dysfunction
QTc prolongation w citalopram
Increased suicidality in under 25s when starting
Hyponatraemia
Increased bleeding risk, particularly elderly
169
What receptors does mirtazapine work on?
Alpha 2 receptor antagonist
H1 antagonist
- hence sedation & increased appetite
170
What receptors do TCAs work on and what are the side effects associated with those?
H1
- sedation, wt gain
M1
- dry mouth, blurred vision, urinary retention, constipation
alpha 1
- hypotension, dizzy
Voltage gated Na channel blockade
- coma, seizures, heart arrhythmias in OD
171
ECG changes in TCA OD
Prolongation of PR, QRS, QT intervals
Non specific ST segment and T wave changes
Atrioventricular block
Right axis deviation
172
Pt presents w altered mental status, sweating, fever, hyperreflexia/clonus on a background of depression
Dx and mx?
Serotonin syndrome
- stop antidepressants
- fluids, supportive care
- sx resolve within 24 hours
'Melting snowman'
173
Signs and sx of serotonin syndrome
Mild
- insomnia, anxiety, nausea, diarrhoea, HTN, hyperreflexia
Moderate
- agitation, myoclonus, tremor, mydriasis, low grade fever
Severe
- hyperthermia, confusion, rigidity, resp failure, coma, death
174
Antidepressant withdrawal syndrome sx
```
Restlessness
Sweating
Electric shock sensations in scalp
Insomnia
GI upset
```
'Flu like sx'
175
Which antidepressants are associated with great withdrawal sx?
Venlafaxine
Paroxetine
(ones with longer half lives, less likely i.e. fluoxetine)
176
True/false for the following sentences:
1. Cyclothymia is cycling of subthreshold symptoms of elevated and depressed mood over a period of at least 2 years
2. A manic episode must always be of more than 7 days in duration
3. Manic patients can demonstrate formal thought disorder
4. The difference between mania and hypomania is the degree of expansive mood
5. A depressive episode is necessary for a diagnosis of BPAD
Cyclothymia is cycling of subthreshold symptoms of elevated and depressed mood over a period of at least 2 years - T
A manic episode must always be of more than 7 days in duration - F
Manic patients can demonstrate formal thought disorder -T
The difference between mania and hypomania is the degree of expansive mood - F
A depressive episode is necessary for a diagnosis of BPAD - F
177
Mood stabiliser drug classes
Lithium
Anti-epileptics
Atypical antipsychotics
178
Lithium toxicity signs
```
Coarse tremor
Marked GI upset
Ataxia
Dysarthria
Impaired consciousness
Epileptic seizures
Nystagmus
Renal failure
```
179
Lithium monitoring
Pre-lithium
- FBC, U&Es, Ca, TFTs, ECG
Monitor weekly serum lithium
Once stable, every 3 months
- U&Es, eGFR, 12hr-serum lithium, TFTs
Reduce to 6 monthly for lower risk patients after a year
180
Which drugs can increase lithium levels thus increase risk of lithium toxicity?
ACEi, NSAIDs
181
Anticonvulsant medication used for acute mania
Sodium valproate (Epilim)
*not to be used in women of child bearing age*
182
Anticonvulsant medication used for BPAD prophylaxis
Sodium valproate (Epilim)
Carbamazepine *strong CYP450 inducer*
Lamotrigine
183
Treatment of acute de novo mania
1. Antipsychotic
- first-line previously untreated due to rapid anti-manic effects
2. Stop any antidepressant monotherapy
3. Adjunctive benzodiazepine
- considered for agitation/insomnia
184
Treatment of acute manic relapse in known bipolar patient
1. Increase dose of mood stabiliser
- if lithium check serum levels and compliance
2. Antipsychotic augmentation
- in addition lithium
3. Antipsychotic for psychosis
- if no severe affective sx, must use these
4. ECT
- if severely manic patients with life-threatening severity
- treatment-resistant mania
- severe mania during pregnancy
185
Bipolar depression tx
Olanzapine with fluoxetine
OR
Lamotrigine and quetiapine
- Requires augmentation w antipsychotic and mood stabiliser
186
Mrs Pearl is a 32 year old woman who has recently had an episode of
pressured speech and delusions that she has the ability to speak
multiple foreign languages. She was found by police attempting to
gain access to the Foreign Office to speak to various government
officials. She was recently treated for depression by her GP.
What should be the first management step her treating team
consider?
A. Commence aripiprazole
B. Commence sodium valproate
C. Stop her antidepressant medication
D. Carry out a CT head scan
C
187
Mr Dunnock is a 57 year old man attending A&E after feeling unwell on
the plane home from a holiday in Spain. He has a diagnosis of bipolar
affective disorder and his wife reports he has been taking all of his
prescribed medication fastidiously.
Rank the following investigations in order of property with (1) being the
highest priority and (5) being the lowest priority:
```
TFTs
Lithium Level
Calcium Level
U&Es
LTFs
```
Lithium level
U&Es
TFTs
- can be affected by Li, may match sx
Calcium level
- can be affected by Li, not as good as much with sx
LFTs
- not affected by Li
188
What does the dopamine theory of psychosis mean for the tx of positive and negative sx?
Positive sx (hallucinations, delusions, thought disorder) due to excessive dopamine thus tx aim to slow down dopamine neurotransmission via mesolimbic and nigrostriatal pathway
Negative sx (alogia, apathy, avolition, asocialty, affective blunting) due to dopamine deficiency thus tx aim to increase dopamine neurotransmission via mesocortical and tuberoinfindibular pathway
189
What are the four dopamine pathways and their associated sx when disrupted?
Mesolimbic: +ve sx in excess DA
Mesocortical: -ve sx in DA deficiency
Nigrostriatal: extrapyramidal SE in DA deficiency
Tuberoinfundibular: hyperprolactinaemia when less active
190
What is high dose antipsychotic tx associated with?
CVD side effects
Metabolic syndrome
Neuroleptic malignant syndrome
191
Antipsychotics with highest risk of causing QTc prolongation
High dose antipsychotic therapy
Haloperidol
Pimozide
(Moderate: quetiapine)
192
Risk factors for neuroleptic malignant syndrome
High dose typical antipsychotics
Rapid dose changes
Male
Younger age
193
Clozapine side effects
AGRANULOCYTOSIS RISK !!!! Monitor WBCs closely
Excessive sedation
Hypersalivation
Postural hypotension (dizziness)
Wt gain and metabolic syndrome
Anti-cholinergic effect (constipation)
Risk of cardiomyopathy and fatal myocarditis
Reduces seizure threshold
Prothrombotic
Severe constipation (sad no poops)
High risk of rebound within 2 weeks if stopped abruptly
194
You are in A&E assessing a man with a known diagnosis of schizophrenia. He is extremely difficult to talk to and says things like... “The train rain brained me. He ate the skate, inflated yesterday’s gate toward the cheese grater”
What symptom is this man displaying?
Clang associations
195
A 78 year old man is visited at home as he did not attend his diabetic clinic appointment. He scores is 14/30 on the MOCA and he is oriented to place but not time. He says he's been feeling very well recently and hasn't needed his medications. When he goes to the kitchen to make you a cup of tea, he returns smoking a cigarette instead.
Which option would be your initial management?
```
A) Minimise cardiovascular risk factors
B) Initiate Donepezil
C) Admit him to hospital for observation
D) Offer him Olanzapine
E) Initiate Sertraline
```
A) Minimise cardiovascular risk factors
196
The son of an 80 year old woman asks you to conduct a home visit as he is concerned that his mother's memory "isn't what it was". She has not been dressing herself in the morning and no longer reads or does the crossword. She has put on weight, become increasingly withdrawn, lethargic; her movements are slowed. Her only significant past medical history is T2 N0 M0 carcinoma of the larynx, successfully treated with radiotherapy 4 years ago.
Which is the most appropriate treatment?
```
A) Fluoxetine
B) Donepezil
C) Levothyroxine
D) Lithium
E) Memantine
```
C) Levothyroxine
197
A) Amisulpride B) Citalopram
C) Moclobamide D) Haloperidol
E) Lithium F) Donepezil
G) Lorazepam H) Propranolol
For each of the side-effects listed below, choose which drug from the list above is most likely to be responsible...
1. Loss of outer third of eyebrows
2. Cogwheel rigidity
3. Hypertensive crisis
4. Anxiety
1. E - lithium
2. D - haloperidol
3. C - moclobamide
4. B - citalopram
198
A 24 year old has been taking Risperidone for 3 weeks. Nursing staff note she "keeps pacing by the door“ and are concerned that she is trying to abscond from the ward. During the consultation she seems on edge and unable to settle. On several occasions she rises from her seat to pace up and down.
What is the mostly likely phenomenon causing her symptoms?
Akathisia
199
A 46 year old man has been treated for paranoid schizophrenia for the last 12 years. His family have noticed that recently he has been grimacing and pulling faces. This seems to be getting worse and they are concerned that he is reacting to hallucinations again.
Which is the most likely cause of his presentation?
```
A) Parkinsonism
B) Tardive dyskinesia
C) Stereotypies
D) Catatonia
E) Dystonia
```
B. Tardive dyskinesia
200
“I’m terrified, there are spiders in my kitchen – I know they’re burrowing into my skin at night”
Which psychopathological term is being demonstrated?
Delusional Parasitosis: Ekboms
- delusional disorder; convinced infestation of parasite/flee/worms
- more common in older pts
- more common women
- associated w severe cleaning behaviours
- hard to treat
201
A 43 yr old man with a 15 yr hx of delusions of being followed by police, running commentary and messages through the BBC news asks about risks
Which of the following should his GP tell him about the long term risk for someone with severe and enduring mental illness?
A. Life expectancy is the same as for the general population
B. Addressing health behaviour and social issues can reduce the gap between people with psychotic disorders and he general population by over 20%
C. Any reduction in life expectancy is largely explained by an increased suicide rate
D. Cardiovascular disease does not excessively contribute to mortality
E. Death rates from cancer are 15% lower than in the general population.
B. Addressing health behaviour and social issues can reduce the gap between people with psychotic disorders and he general population by over 20%
202
Keisha is a 30 year-old woman with bipolar affective disorder.
She is currently well and treated with lithium. She presents to you in general practice as she and her husband are planning to start a family. Which of the following is true?
A. Keisha should discontinue her medication to avoid risk of harm to the foetus
B. Keisha is very likely to relapse during pregnancy if she discontinues medication
C. Bipolar affective disorder does not increase the risk of puerperal psychosis
D. Lithium is generally safe in pregnancy and breastfeeding
E. Keisha’s child is no more likely to develop a mood disorder compared to the general population
B. Keisha is very likely to relapse during pregnancy if she discontinues medication
203
In bipolar disorder, which of the following is correct?
A. It typically presents with delusions of control.
B. Hypermania is a severe form of mania.
C. Depressive episodes are usually accompanied by psychotic symptoms.
D. Manic episodes are often associated with irritability rather than elevated mood.
E. At least 3 episodes of mania are required for the diagnosis.
D. Manic episodes are often associated with irritability rather than elevated mood.
204
A 78 year old man with severe depressive illness is referred to your clinic and started on an antidepressant. A few weeks later he is admitted to hospital with symptomatic hyponatraemia.
Which medication is most likely to have caused this?
```
A. Amitriptyline
B. Citalopram
C. Mirtazapine
D. Duloxetine
E. Trazadone
```
B. Citalopram
205
A 24 year old woman is hospitalised after superficially slashing both her wrists. At the ward round 3 days later, the male CT doctor argues she has been doing well, but the nursing staff become angry, saying he is showing favouritism towards the patient, despite her being non-compliant with the ward rules.
Which psychological treatment is recommended by NICE for this patient?
DBT
206
A 28 year old taxi driver is chronically consumed by fears of having run over a pedestrian. Although he tries to convince himself his worries are silly, his anxiety continues to mount until he drives back to the scene of the ‘accident’ and proves to himself that nobody lies hurt in the street.
This behaviour is consistent with:
A) An obsession secondary to a compulsion
B) A compulsion triggered by an obsession
C) A delusional ideation
D) A typical manifestation of anankastic personality disorder
E) A phobia
B) A compulsion triggered by an obsession
207
A 52 year old woman with chronic schizophrenia, tells her psychiatrist that: “I know it sounds silly, but I can’t get it out of my head that my baby has been exchanged by my neighbours’ little girl”
What is she experiencing?
```
A) Capgras Syndrome
B) Thought alienation
C) Overvalued Ideas
D) Persecutory delusions
E) Obsessions
```
E) Obsessions
208
Rank the following treatments in order of appropriateness as first line (1 = most app, 5 = least app)
A 34 yo secretary climbs 12 flights of stairs every day to reach her office because she is terrified by the thought of being trapped in the lift. She has never had any traumatic event occur in a lift; but has been terrified of them since little
```
Exposure therapy
EMDR
Prescribe sertraline 50mg
CBT
Psychodynamic psychotherapy
```
```
Exposure therapy
CBT
Psychodynamic psychotherapy
Sertraline 50mg
EMDR
```
209
Sunil is a 28 year-old man who was involved in a road traffic collision yesterday. His cousin who was driving was killed. Since admission to hospital Sunil has been aggressive and irritable.
Which of the following is TRUE in an acute stress reaction?
A. It may arise up to 6 months after the event
B. It rarely resolves without treatment
C. Both depersonalisation and derealisation are recognized features
D. Psychological debriefing during an acute stress reaction decreases the risk of developing later PTSD
E. Pharmacological treatment is contraindicated
C. Both depersonalisation and derealisation are recognized features
210
A middle-aged man is pre-occupied with his health. For many years he feared his irregular bowel functions meant he had cancer. Now he is very worried about serious heart disease, despite his physician’s assurance that the occasional ‘extra beats’ he detects are benign.
What is the most likely diagnosis?
```
A) Somatization disorder
B) Hypochondriasis
C) Delusional disorder
D) Pain disorder
E) Conversion disorder
```
B) Hypochondriasis
211
A 68 year-old man whose wife recently had an ischaemic stroke presents with sudden onset of bilateral leg paralysis. On examination he denies sensation to the groin, though twitches slightly as you test pinprick sensation. Reflexes and tone are normal. Motor function is 0/5 throughout, though staff report they have noticed him moving his legs while he is sleeping. CT and nerve conduction studies are normal.
What is the most appropriate management?
A. Rest for 4-6 weeks followed by gradual increase in activity levels
B. Reassure him that symptoms resolve completely in 75% of cases
C. Provide a temporary wheelchair to improve mobility and independence
D. Reassure him that normal function should return quickly
E. Avoid providing further care for his wife, since this will reinforce his symptoms
B. Reassure him that symptoms resolve completely in 75% of cases
212
A 35 yo phlebotomist from a family of nurses is admitted with abdominal pain.
She has multiple abdominal scars and marked abdominal tenderness. She is evasive when about where the procedures happened but can describe in detail what was done in each. Which of the following is she experiencing?
```
A. Somatisation disorder
B. Hypochondriasis
C. Malingering
D. Schizophreniform disorder
E. Conversion disorder
```
A. Somatisation disorder
213
A 38 yo man is concerned about the side effects of a new medication he was prescribed.
He had initially presented with low mood & anxiety. He was struggling to finish work projects on time and without mistakes, often getting distracted and feeling very bored at "mind numbing" tasks.
A specialist psychiatric team diagnosed him and prescribed regular medication.
Since starting the medication this has improved, and he is also got better at not constantly losing his keys and forgetting family events. He notes that he now has more patience with his rather hyper 12 yo son too.
His mother reported that this is the best she's seen him, since he had issues with being rather chaotic, naughty and forgetful since he was a child.
Which side effect might he experience from the medication prescribed for his condition?
```
A. Early morning waking
B. Sedation
C. Increased appetite
D. Bradycardia
E. Weight loss
```
E. Weight loss
214
A 27 year old woman attends the emergency department with restlessness, anxiety and insomnia for the past 24h. On examination, she has watery eyes, profuse nasal secretions, sweating, shivering, dilated pupils and tachycardia.
Which of the following is the most probable cause of this woman’s presentation?
```
A. Heroin withdrawal
B. Amphetamine intoxication
C. Alcohol withdrawal
D. Cannabis intoxication
E. Cocaine withdrawal
```
A. Heroin withdrawal
215
In clinic, a 69 year old man states he was on the way to meet some friends but has become lost. He tries to shoo away the "dogs" he says have been following him around. He has a mild tremor at rest and his gait is slightly stiff. He denies having had any medical problems recently and says he feels "right as rain".
Which would be the best treatment?
```
A) Thyroxine
B) Sertraline
C) Donepezil
D) Olanzapine
E) L-Dopa
```
C) Donepezil
216
A 32 year old woman is brought to A and E complaining of chest pain. She is noted to be hypervigilant and anxious, with a pulse of 120 bpm and a BP of 140/97. She has widely dilated pupils. Her urine drug screen is positive .
Which of the following drugs is she most likely to have used?
```
A) Cocaine
B) Phenylphenidate (Ritalin)
C) Heroin
D) Diazepam
E) Cannabis
```
A) Cocaine
217
Unilateral vs bilateral ECT
Unilateral
- two electrodes on non-dominant hemisphere
- fewer cognitive side effects
- not as effective/slower action
Bilateral
- one electrode on each hemisphere (devil horn)
- more cognitive side effects
- more effective/faster action
218
What is ECT?
Treatment that involves sending an electric current through your brain, causing a brief surge of electrical activity within your brain (also known as a seizure)
6-12 sessions, twice a week (CBT vibes)
219
When is ECT indicated?
Severe or life-threatening depression and your life is at risk so you need urgent treatment
Moderate to severe depression and other treatments such as medication and talking therapies haven't helped you
Catatonia (staying frozen in one position, or making very repetitive or restless movements)
A severe or long-lasting episode of mania
220
Common ECT side effects
80%
Confusion, muscle pain, headache, nausea
10%
Cognition - retrograde, anterograde amnesia
*should recover within 6 months
