Psych

Question 1

Somatisation disorder

Answer 1

• Multiple physical SYMPTOMS present for at least 2 years
• Patient refuses to accept reassurance or negative test results

Question 2

Hypochondrial disorder

Answer 2

Persistent belief in the presence of an underlying serious DISEASE, e.g. Cancer
* Patient again refuses to accept reassurance or negative test results

Question 3

Conversion disorder

Answer 3

Typically involve loss of motor or sensory function
* Some patients may experience secondary gain from loss of function
* Patients may be indifferent to their apparent disorder
* Psychogenic aphonia is a form of conversion disorder: not speaking after a shocking event.

Question 4

Dissociative disorder

Answer 4

• Dissociation is a process of ‘separating off’ certain memories from normal consciousness
• In contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
• Dissociative identity disorder (DID) is the new term for multiple personality disorder as is the
  most severe form of dissociative disorder

Question 5

Body dysmorphic disorder

Answer 5

Diagnostic and Statistical Manual (DSM) IV criteria:
* Preoccupation with an imagine defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive
* The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
* The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa)

Question 6

Post-traumatic stress disorder (PTSD) features

Answer 6

• Re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
• Avoidance: avoiding people, situations or circumstances resembling or associated with the
  event
• Hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems,
  irritability and difficulty concentrating
• Emotional numbing - lack of ability to experience feelings, feeling detached from other people
• Depression
• Drug or alcohol misuse
• Anger
• Unexplained physical symptoms

Question 7

Post-traumatic stress disorder (PTSD) treatment

Answer 7

Management
* Following a traumatic event single-session interventions (often referred to as debriefing) are not recommended
* Watchful waiting may be used for mild symptoms lasting less than 4 weeks
* Trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and
reprocessing (EMDR) therapy may be used in more severe cases
* Drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug
treatment is used then paroxetine or mirtazapine are recommended

Question 8

Post-concussion syndrome

Answer 8

Typical features include
* Headache
* Fatigue
* Anxiety/depression * Dizziness

Question 9

‘Baby-blues’

Answer 9

Seen in around 60-70% of women
Typically 3-7 days following birth and more common in primips
Mothers: characteristically anxious, tearful and irritable

Question 10

Postnatal depression

Answer 10

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

Question 11

Puerperal psychosi

Answer 11

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

Question 12

Schizophrenia:

Answer 12

Auditory hallucinations of a specific type:
* Two or more voices discussing the patient in the third person
* Thought echo
* Voices commenting on the patient’s behaviour
Thought disorder (occasionally referred to as thought alienation):
* Thought insertion
* Thought withdrawal
* Thought broadcasting
Passivity phenomena:
* Bodily sensations being controlled by external influence
* Actions/impulses/feelings - experiences which are imposed on the individual or influenced by
others
Delusional perceptions
* A two stage process: where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. ‘the traffic light is green therefore i am the king’.

Question 13

SCZ Factors associated with poor prognosis

Answer 13

Strong family history
* Gradual onset
* LowIQ
* Premorbid history of social withdrawal
* Lack of obvious precipitant

Question 14

SCZ Risk of developing schizophrenia

Answer 14

Monozygotic twin has schizophrenia = 50%
* Parent has schizophrenia = 10-15%
* Sibling has schizophrenia = 10%
* No relatives with schizophrenia = 1%

Question 15

Alcohol withdrawal
time frame

Answer 15

• Symptoms: 6-12 hours
• Seizures: 36 hours
• Delirium tremens: 72 hours

Question 16

Alcohol withdrawal mechanism

Answer 16

Mechanism
* Chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
* Alcohol withdrawal is thought to lead to the opposite (↓ inhibitory GABA and ↑ NMDA glutamate transmission)

Question 17

Bulimia nervosa management

Answer 17

Management
* Referral for specialist care is appropriate in all cases
* Cognitive behaviour therapy (CBT) is currently consider first-line treatment
* Interpersonal psychotherapy is also used but takes much longer than CBT
* Pharmacological treatments have a limited role - a trial of high-dose fluoxetine is currently
licensed for bulimia but long-term data is lacking

Question 18

Anorexia features

Answer 18

Most things low
* G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinemia

Question 19

Hospitalized patients with AN and NGT feeding are at risk of

Answer 19

f refeeding syndrome, which can
lead to profound hypophosphatemia

Question 20

actors associated with risk of suicide following an episode of deliberate self harm:

Answer 20

Efforts to avoid discovery * Planning
* Leaving a written note
* Final acts such as sorting out finances * Violent method

Question 21

Serotonin Syndrome features

Answer 21

Features
* Agitation
* Hyperthermia
* Tachycardia
* Labile BP
* Hyperreflexia and ↑ tone

Question 22

Serotonin Syndrome drugs

Answer 22

SSRI
* MAOI (e.g. Moclobemide)

Question 23

Restless legs syndrome (RLS)

Answer 23

• Uncontrollable urge to move legs (akathisia). Symptoms initially occur at night but as condition progresses may occur during the day. Symptoms are worse at rest
• Paraesthesias e.g. ‘Crawling’ or ‘throbbing’ sensations
• Movements during sleep may be noted by the partner - periodic limb movements of sleeps
  (PLMS)

Question 24

RLS Causes and associations

Answer 24

• There is a positive family history in 50% of patients with idiopathic RLS
• Iron deficiency anaemia
• Uraemia
• Diabetes mellitus
• Pregnancy

Question 25

RLS managment

Answer 25

Management
* Simple measures: walking, stretching, massaging affected limbs
* Treat any iron deficiency
* Dopamine agonists are first-line treatment (e.g. Pramipexole, ropinirole)
* Benzodiazepines
* Gabapentin

Question 26

antipsychotics - Extrapyramidal side-effects

Answer 26

Extrapyramidal side-effects
* Parkinsonism
* Acute dystonia (e.g. Torticollis, oculogyric crisis)
* Akathisia (severe restlessness)
* Tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur
in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)

Question 27

antipsychotics other side-effects/features

Answer 27

ther side-effects/features
* Antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
* Sedation, weight gain
* Raised prolactin: galactorrhoea
* Neuroleptic malignant syndrome: pyrexia, muscle stiffness
* ↓ seizure threshold (greater with atypicals)
* Antipsychotics are not addictive

Question 28

Olanzapine, like other atypical antipsychotics,

Answer 28

is known to block serotonin receptors
(especially 5-HT2 subtype) as well as D2 dopamine receptors

Question 29

Adverse effects of atypical antipsychotics

Answer 29

• Weight gain
• ↑ risk of venous thromboembolism
• Olanzapine and risperidone are associated with an ↑ risk of stroke in elderly patients
• Clozapine is associated with agranulocytosis (see below)

Question 30

Adverse effects of clozapine

Answer 30

• Agranulocytosis (1%), neutropaenia (3%)
• ↓ seizure threshold - can induce seizures in up to 3% of patients

Question 31

Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment for the majority of patients with depression:
how to pick

Answer 31

Citalopram and fluoxetine are currently the preferred ssris
* Citalopram is useful for elderly patients as it is associated with lower risks of drug interactions
* 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

Question 32

Adverse effects SSRIs

Answer 32

Gastrointestinal symptoms are the most common side-effect
* There is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump
inhibitor should be prescribed if a patient is also taking a NSAID
* Patients should be counselled to be vigilant for increased anxiety and agitation after starting a
SSRI
* Fluoxetine and paroxetine have a higher propensity for drug interactions
* Citalopram and sertraline and more suitable for patients with chronic physical health problems
as they have a lower propensity for drug interactions.

Question 33

Interactions SSRIs

Answer 33

NSAIDs: NICE advised ‘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: see above
* Triptans: avoid SSRIs

Question 34

Discontinuation symptoms SSRI

Answer 34

Increased mood change
* Restlessness
* Difficulty sleeping
* Unsteadiness
* Sweating
* Gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
* Paraesthesia

Question 35

Tricyclic antidepressants Common side-effects:

Answer 35

• Drowsiness * Constipation * Blurred vision
• Dry mouth * Urinary retention

Question 36

Choice of tricyclic

Answer 36

Low-dose amitriptyline is commonly used in the management of neuropathic pain and the prophylaxis of headache (both tension and migraine)
* Lofepramine has a lower incidence of toxicity in overdose
* Amitriptyline and dosulepin (dothiepin) and considered the most dangerous in overdose

Question 37

Neuroleptic Malignant Syndrome

Answer 37

Features
* More common in young ♂ patients
* Onset usually in first 10 days of treatment or after increasing dose
* Pyrexia
* Rigidity
* Tachycardia
A raised creatine kinase is present in most cases. A leukocytosis may also be seen