Psych

Question 1

PTSD mx

Answer 1

trauma-focused cognitive behavioural therapy or EMDR

If CBT or EMDR therapy are ineffective in PTSD, the first line drug treatments are venlafaxine or a SSRI

Question 2

Tangentiality

Answer 2

Person’s response to a question is irrelevant or veers off topic. The person doesn’t return to the original point or answer the initial question.

Question 3

Mx of panic disorder

Answer 3

SSRI

Question 4

Measurements taken before starting antipsychotic medication

Answer 4

weight, waist circumference, pulse and BP, bloods (including fasting glucose, HbA1c, lipids and prolactin), assessment of movement disorders and nutritional status.

Question 5

Monitoring of patients on antipsychotics

Answer 5

Annual- FBC, urea, electrolytes, LFT

Fasting glucose, prolactin- 6 months

Lipids, weight- 3 months

Question 6

SSRI in pregnancy

Answer 6

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

Question 7

Clozapoine SE

Answer 7

weight gain
excessive salivation
agranulocytosis
neutropenia
myocarditis
arrhythmias
reduced seizure threshold - can induce seizures in up to 3% of patients

Dose adjustment of clozapine might be necessary if smoking is started or stopped during treatment.

Question 8

Atypical antipsychotics

Answer 8

clozapine
olanzapine: higher risk of dyslipidemia and obesity
risperidone
quetiapine
amisulpride
aripiprazole: generally good side-effect profile, particularly for prolactin elevation

These drugs have a more complex mechanism of action that includes blocking serotonin (5-HT2A) receptors in addition to dopamine receptors.

Question 9

Alcohol withdrawal timeline

Answer 9

symptoms: 6-12 hours-tremor, sweating, tachycardia, anxiety

seizures: 36 hours

delirium tremens: 72 hours
oarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia

Question 10

Antidepressant length of treatment

Answer 10

Antidepressants should be continued for at least 6 months after remission of symptoms to decrease risk of relapse
12 months in the elderly and 2 years in those with a history of recurrent depression

Question 11

Stopping SSRI

Answer 11

dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.

Question 12

Discontinuation symptoms

Answer 12

increased mood change
restlessness
difficulty sleeping
unsteadiness
sweating
gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
paraesthesia

Question 13

Classification of depression

Answer 13

‘less severe’ depression:
a PHQ-9 score of < 16

‘more severe’ depression:
a PHQ-9 score of ≥ 16

Question 14

Mx of depression

Answer 14

Less severe
Psychological

More severe
Antidepressant and SSRI

Question 15

Acute dystonic reaction sx and mx

Answer 15

Oculogyric crisis- neck is fixed backwards and laterally, and her eyes are deviated upwards. She is unable to control her gaze.

tongue protrusion and jaw spasm.

Treatment is usually IV procyclidine and withdrawal of the causative medication.

Question 16

Tardive dyskinesia

Answer 16

Side effect of antipsychotics that occurs after many years. It typically affects the face and involves repetitive, involuntary, writhing movements such as grimacing, tongue protrusion and lip smacking.

Question 17

Clang associations

Answer 17

ideas are related to each other only by the fact they sound similar or rhyme.

Question 18

Word salad vs Knight’s move thinking

Answer 18

completely incoherent speech where real words are strung together into nonsense sentences.

oosening of associations, where there are unexpected and illogical leaps from one idea to another. It is a feature of schizophrenia.

Question 19

Obsessive-compulsive personality

Answer 19

Perfectionism at the expense of completing tasks
(Anankastic personality disorder)

Question 20

OCD vs OCPD

Answer 20

It is different to obsessive-compulsive disorder in a number of ways, one being that in OCD, thoughts and behaviours are seen as unwanted/unhealthy, being the product of anxiety-inducing and involuntary thoughts, whereas in OCPD they are egosyntonic

Question 21

Paranoid, schizoid and schizotypal PD

Answer 21

Paranoid
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

Schizoid
Indifference to praise and criticism
Preference for solitary activities
Lack of interest in sexual interactions
Lack of desire for companionship
Emotional coldness

Schizotypal
Odd beliefs and magical thinking
Paranoid ideation and suspiciousness
Odd, eccentric behaviour
Lack of close friends other than family members
Inappropriate affect
Odd speech without being incoherent

Question 22

Neuroleptic malignant syndrome

Answer 22

life-threatening reaction to antipsychotic drugs characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction.

Question 23

Section 135 and 136

Answer 23

Section 135
a court order can be obtained to allow the police to break into a property to remove a person to a Place of Safety

Section 136
someone found in a public place who appears to have a mental disorder can be taken by the police to a Place of Safety
can only be used for up to 24 hours, whilst a Mental Health Act assessment is arranged

Question 24

Section 2 vs 3

Answer 24

Section 2
admission for assessment for up to 28 days, not renewable
an Approved Mental Health Professional (AMHP) or rarely the nearest relative (NR) makes the application on the recommendation of 2 doctors
one of the doctors should be ‘approved’ under Section 12(2) of the Mental Health Act (usually a consultant psychiatrist)
treatment can be given against a patient’s wishes

Section 3
admission for treatment for up to 6 months, can be renewed
AMHP along with 2 doctors, both of which must have seen the patient within the past 24 hours
treatment can be given against a patient’s wishes

Question 25

Section 5(2) vs 5(4)

Answer 25

Section 5(2) a patient who is a voluntary patient in hospital can be legally detained by a doctor for 72 hours Section 5(4) similar to section 5(2), allows a nurse to detain a patient who is voluntarily in hospital for 6 hours

Question 26

Antisocial, Borderline (Emotionally Unstable), Histrionic and Narcissistic PD

Answer 26

Antisocial 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 Lack of remorse Borderline Unstable interpersonal relationships which alternate between idealization and devaluation Unstable self image Impulsivity in potentially self damaging area Histrionic Inappropriate sexual seductiveness Need to be the centre of attention Rapidly shifting and shallow expression of emotions Suggestibility Narcissistic 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

Question 27

Obsessive compulsive, avoidant and dependent PD

Answer 27

OC- 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 Avoidant Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection. Preoccupied with ideas that they are being criticised or rejected in social situations Restraint in intimate relationships due to the fear of being ridiculed Dependent 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

Question 28

Unexplained symptoms conditions

Answer 28

Somatisation = Symptoms hypoChondria = Cancer

Question 29

Association with poor prognosis schizo

Answer 29

strong family history gradual onset low IQ prodromal phase of social withdrawal lack of obvious precipitant

Question 30

Which class of antidepressants are now less commonly used due to their toxicity in overdose?

Answer 30

TCA narrow therapeutic index and therefore become potent cardiovascular and CNS toxins in moderate doses. prolonged hypotension, cardiac arrhythmias, and seizure

Question 31

Breast tenderness, breast enlargement and lactation on antipsychotic and mx

Answer 31

Hyperprolactaemia Switch to Aripiprazole

Question 32

Risk of antipsychotics are used in elderly patients

Answer 32

increased risk of stroke increased risk of venous thromboembolism

Question 33

Experiencing sedation with mirtazipine

Answer 33

Increase the dose Mirtazapine is generally more sedating at lower BNF doses

Question 34

Section 4

Answer 34

72 hour assessment order used as an emergency, when a section 2 would involve an unacceptable delay a GP and an AMHP or NR often changed to a section 2 upon arrival at hospital

Question 35

Length of time for classification of depressive episode

Answer 35

2 weeks

Question 36

Depressive episode sx

Answer 36

loss of interest in things you would normally find pleasure in (anhedonia), and reduced energy levels (anergia).

Question 37

Affect vs mood

Answer 37

Affect is the current, observed emotional state of the patient (what you see), whereas mood is the more pervasive, predominant state over a longer period (what you ask about)

Question 38

Schneider's First Rank Symptoms

Answer 38

A - Auditory hallucination B - Broadcasting of thought C - Control delusions (passivity of affect, volition, impulse, somatic) D - Delusional perception E - Entry / Exit of thought (thought insertion, withdrawal)

Question 39

Meds interacting with SSRI

Answer 39

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

Question 40

When to start clozapine

Answer 40

indicated for patients with schizophrenia who have not responded adequately to at least 2 antipsychotics

Question 41

Delusion vs schizo

Answer 41

Delusion- fixed false beliefs Schizo -additional symptoms such as hallucinations, disorganised thinking, or significant functional impairment.

Question 42

Adjustment disorders

Answer 42

low mood and stress began in response to a clear external stressor (job loss). The symptoms are relatively mild and short-term, and there is no history of more severe mood disturbances

Question 43

Alcohol withdrawal mechanism

Answer 43

Alcohol withdrawal results from decreased inhibitory GABA and increased NMDA glutamate transmission

Question 44

Mania vs hypomania

Answer 44

Mania Lasts for at least 7 days - Causes severe functional impairment in social and work setting May require hospitalization due to risk of harm to self or others May present with psychotic symptoms e.g. delusions of grandeur, auditory hallucinations Hypomania Lasts for < 7 days, typically 3-4 days. Can be high functioning and does not impair functional capacity in social or work setting Unlikely to require hospitalization Does not exhibit any psychotic symptoms

Question 45

PTSD sx

Answer 45

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

Question 46

Extrapyramidal side-effects (EPSEs)

Answer 46

Parkinsonism acute dystonia sustained muscle contraction (e.g. torticollis, oculogyric crisis) may be managed with procyclidine 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 47

SSRI post MI

Answer 47

Sertraline

Question 48

Most common SE of olanzapine

Answer 48

Weight gane

Question 49

Conversion vs somatisation

Answer 49

- conversion: stress is converted into a neurological symptoms - somatisation: so many symptoms for such a long time (2yr) This condition involves multiple unexplained physical symptoms across different body systems, causing significant distress and impairment in daily functioning. These symptoms cannot be explained by any medical condition or substance use.

Question 50

What can cause a rise in clozapine levels

Answer 50

Smoking cessation

Question 51

SSRI causing torsades

Answer 51

Citalopram- prolonges QT

Question 52

Cortard syndrome

Answer 52

Patients believes they are dead

Question 53

Capgras syndrome

Answer 53

europsychiatric phenomenon in which patients believe that a partner/family member/friend has been replaced by an imposter.

Question 54

SNRIs

Answer 54

Venlafaxine and duloxetine

Question 55

Anorexia nervose biochem

Answer 55

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

Question 56

Mx of suicidal pt who is suicidal as GP

Answer 56

CRISIS team

Question 57

When to use ECT

Answer 57

patients with severe depression refractory to medication (e.g. catatonia) those with psychotic symptoms. The only absolute contraindications is raised intracranial pressure.

Question 58

SE of ECT

Answer 58

Short-term side-effects headache nausea short term memory impairment memory loss of events prior to ECT cardiac arrhythmia Long-term side-effects some patients report impaired memory

Question 59

Section 17

Answer 59

A community treatment order (CTO) can be used to recall a patient to hospital for treatment if they do not comply with conditions of the order in the community, such as complying with medication

Question 60

On warfarin which antidepressant

Answer 60

Mirtazipine

Question 61

SE more common in atypical than typical

Answer 61

Weight gain

Question 62

Adverse effects of lithium

Answer 62

nausea/vomiting, diarrhoea fine tremor nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus thyroid enlargement, may lead to hypothyroidism ECG: T wave flattening/inversion weight gain idiopathic intracranial hypertension leucocytosis hyperparathyroidism and resultant hypercalcaemia

Question 63

Monitoring lithium

Answer 63

Level taken 12 hrs after dose once established, lithium blood level should 'normally' be checked every 3 months after a change in dose, lithium levels should be taken a week later and weekly until the levels are stable. thyroid and renal function should be checked every 6 months

Question 64

How to differentiate between organic and non organic leg paresis

Answer 64

Hoover sign In non-organic paresis, pressure is felt under the paretic leg when lifting the non-paretic leg against pressure, this is due to involuntary contralateral hip extension

Question 65

What type of incontinence do TCA cause

Answer 65

Overflow- anticholinergic

Question 66

Mx of diazepam addiction

Answer 66

switch patients to the equivalent dose of diazepam reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg time needed for withdrawal can vary from 4 weeks to a year or more

Question 67

Malingering

Answer 67

fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain

Question 68

Munchausen's syndrome/Factitous

Answer 68

the intentional production of physical or psychological symptoms

Question 69

Dissociative disorder

Answer 69

dissociation is a process of 'separating off' certain memories from normal consciousness