Psych Flashcards

Question

Components of perception

Answer 1

Have you seen or head thing sthat other people can't see or hear Illusions Hallucinations Pseudo-hallucinations

Answer 2

Misinterpretations of normal perceptions: can occur in healthy people

Answer 3

Perceptions in absence of abnromal stimulus, experienced as true and coming from the outside world Can take any medium, though auditory and visual are most common

Answer 4

Internal perceptions with preserved insight

Answer 5

Can be tested formally using MMSE Should test: G- general: Alertness and Co-operation O- orientation: Time and Place A- attention: WORLD backwards and Serial Sevens L- language: Naming and Repetition C- calculation: Division and Subtraction R- right Hemisphere Function: Intersecting pentagons and Clock-face A- abstraction: Proverbs and Similarities M- memory: Short term and Long-term memory P- praxis: Wave good-bye and Comb hair

Answer 6

Patient's understanding of their own condition and its cause

Answer 7

Discriminating: occur commonly in a defined syndrome but rarely in other syndromes Characteristic: occur frequently in the defined syndrom eubt also occur in other syndormes

Answer 8

Self-harm Harm to others (including children!!) Risk of self-neglect and accidental harm Vulnerability to abuse

Answer 9

Risk of self harm: current thoughts and plans Protective factors Previous episdoes Factors predisposing to deliberate self-harm/suicide: 1. Fhx 2. Social isolation 3. Substance Misuse Any Hx of previous disengagemnt from support services In MSE: thoughts of hopelessness and worthlessness. Command hallucinations inciting self harm

Answer 10

Acts/threats of violence Deliberate arson Sexually inappropritae behaviour Epsiodes of containemnt Extent of compliance Increased risk if: * Recent discontinuation of Rx * Change in use of recreational drugs * Alcohol or drug misuse (or other disinhibiting factors) * Impulsive/unpredictable behaviour * Recent stressful life events In MSE look for: * Expressed violent intentions or threats * Irritability, disinhibition, suspiciousness * Persecutory delusions * Delusions of control/passivity * Command hallucinations Risk to children

Answer 11

HOme safety Wandering Self-neglect Abuse, neglect, crime vulnerability Eating (malnutirition)

Answer 12

Intentional self- inflicted eath 1/10,000 p annum M\>F (older men) RFs: * Availability of means * Social support * Life events * Mental illness: * Depression * Schizophrenia * Substance misuse * Emotionally unstable or antisocial personality disorder * Eating disorder Chronic painful illnesses FHx

Answer 13

Intentional non-fatal self-inflicted harm 2-3/1000 pa F\>M (younger women RFs: * Availability of means * Social support * Life events * Mental illness: * Depression * Schizophrenia * Substance misuse * Emotionally unstable or antisocial personality disorder * Eating disorder Unemployed, divorce Socio-economic deprivation

Answer 14

Depression Bipolar Schizophrenia Alcoholism Substance misuse Prsonlaity disorder (persent in 30-60% of completed suicides especially emotionally unstable/borderline Anorexia nervosa

Answer 15

Misinterpretation of thoughts and perceptions that arise from the patient's own mind/imagination as reality and include delusions and hallucinations

Answer 16

Schizophrenia Schizoaffective disorder Delusional disorder Brief psychotic episodes BPAD Drug-induced Psychotic depression

Answer 17

15-20/100000 0.7% lifetime risk Men\>Women Peak incidence in late teens or early adulthood

Answer 18

* Third-person auditory hallucinations (discussion/giving running commentary) * Thought echo (hear own thoughts out loud) * Delusional perception (a bunch of flowers-\>therefore I knew terrorists were after me) * TI/TB/TW * Passivity

Answer 19

First rank are discriminatory: also occur in 8% of patients with BPAD, whil 20% with chronic schizophrenia never show them Second rank sympomts: characteristics, include catatonic behaviour and 2nd person auditory hallucinations

Answer 20

First Rank symptom or persistent delusion Present for at least a month (ICD10) (6 monhts in DSM) No drug intoxication, withdrawal, organic disease or prominent affective symptoms

Answer 21

Persecutory Delusions of reference

Answer 22

Loosening of associations Neologisms Concrete thinking (inability to deal with abstract ideas) Word salad

Answer 23

Positive (hallucinations/delusions) Negative (poverty of speech, flat affect, poor motivation, social withdrawal) Cognitive (poor attention and memory)

Answer 24

Paranoid Cataotnic Hebephrenic (disorganised) Residual Undifferentiated (simple)

Answer 25

Most common, delusions and auditory hallucinations

Answer 26

Typical symptoms: Psychomotor disturbances (alternating between morot immobility and excessive activity) Rigidity Abnormal posturing Echolalia (copying speech) Echopraxia (copying behaviours)

Answer 27

(Disorganised) Early onset and poor prongosis. Behaviour is irresponible and unpredictable Mood inappropriate and incongruous affect. Thought incoherence, fleeting delusions and hallucinations occur

Answer 28

Falls into one of the other types but negative symptoms predominate

Answer 29

Negative symptoms without preceding over psychotic symptoms

Answer 30

Anxiety, depression and ideas of reference

Answer 31

Genetics: FHx/sibling hx specifically Neurodevelopmental hypothesis: * (increased rates associated with winter births, obstetric complications, developmental delay, soft neurological signs, temporal lobe epilpepsy, smoking cannabis in adolescence.) * Social factors: socioeconomic deprivation, urban area, excess of life events. * High er in Afrocarribean Neurochemical: * Dopamine excess in mesolimbic pathways * Increased serotonin activity * Decreased glutamate activity.

Answer 32

Affective and schizophrenic symptoms occur together and with equal prominence

Answer 33

Fixed delusion or delusional system with other areas of thinking and funcitoning well preserved

Answer 34

Last less time than required for schizophrenia diagnosis.

Answer 35

1 f (obsessional images) 2 b 3 h 4 a 5 d 6 g 7 i

Answer 36

2 Delusions 1 b 2 h 3 f 4 d 5 e 6 a

Answer 37

2. D; Psychotic disorders take precedence over mood disorders.

Answer 38

3. C; There is always a duty when you are made aware of a specific risk to a named indvidual. For A and B, whether to do so would depend on whether the victim had capacity to make decision to refuse help. For D, there is a duty to disclose information that may help prevent or detect serious crime, but not all crime.

Answer 39

4. B; All may be useful, but only B is essential in all cases. Patients may underestimate or not disclose the full extent of their overdose.

Answer 40

6. C; Note it is hallucinations, not illusions, that are characteristic of psychosis.

Answer 41

SSRIs Citalopram and fluoxetine Sertraline as there is more evidence for safe use in this situation Fluoxetine

Answer 42

GI symptoms Increased risk of GI bleed therefore a PPI should be co-prescribed Patients should be counselled to be vigilant for increased anxiety and agitation Fluoxetine and paroxetine

Answer 43

Citalopram and escitalopram are associated with dose-dependant QTI prolongation Should not be used in patients with congenital long QT, known pre-exisiting QT interval prolongation or in combination that prolong the QT intrval 40mg for adults 20mg for \>65y/o or those with hepatic impairment

Answer 44

NSAIDs (not normally recommended, if necessary add PPI) Warfarin/heparin, avoid SSRI and consider mirtazapine Aspirin (as above) Triptans: avoid SSRIs

Answer 45

Noradrenergic and specific serotonergic antidepresssant Constipation, dry mouth, increased appetiete Somnolence Weight gain ALT raised TGs Dizziness

Answer 46

Tapered over 4 weeks Increased mood change Restlenssness Difficulty sleeping Unsteadiness Sweating GI symptoms Paraesthesia

Answer 47

P450 Inducer. Effective as TCA in treatment of mild-moderate depression Thought to be similar MOA to SSRIs.

Answer 48

Can cause serotonin syndrome P450 inducer, may also reduce effectiveness of OCP

Answer 49

No as uncertainty about dose, variation in preparations and potential serious ADIs.

Answer 50

Effforts to avoid discovery Planning Note Fina acts e.g. will Violent method

Answer 51

R/v at 2 weeks ( If a patient makes a good response they should continue on treatment for at least 6 months as this reduces risk of relapse

Answer 52

Reduciton in extra-pyramidal side effects Weight gain Clozapine is associated with agranulocytosis

Answer 53

Increased risk of stroke (espedcially olanzapine and risperidone) Increased risk of VTE

Answer 54

Olanzapine and risperidone

Answer 55

Clozapine Olanzapine Risperidone Quetiapine Amusulpride

Answer 56

Should only be used in patients with psychosis that is resistant to other antipsychotics Agranulocytosis and neutropenia Reduced seizure threshold: can induce seizures in up to 3%

Answer 57

Drowsiness Dry mouth Blurred vision Constipation Urinary retnetion Due to anti-muscarininc effects

Answer 58

Amitryptilline, clompiramine, dosulepine, trazodone Imipramine, lofepramine, nortriptyline

Answer 59

Blurred vision and dry outh?

Answer 60

Management of neuropathic pain and headache prohpylaxis

Answer 61

Amitryptilline and dosulepin Loferpramine

Answer 62

no cognitive impairment=24-30; mild cognitive impairment=18-23; severe cognitive impairment=0-17

Answer 63

Reduced BMI Bradycardia Hypotension Enlarged salivary glands

Answer 64

Hypokalaemia Low FSH, LH and sex hormones Raised cortisol and GH IGTT Hypercholesterolaemia Hypercartoniaemia Low T3

Answer 65

Flashbacks Avodiance Hyperarousal Emotional numbing Derpession, drug or ETOH misues, anger, unexplained physical symptoms

Answer 66

Mild symptoms CBT and EMDR used in more severe Drug treatment is not first line If drug treatment used: paroxetine or mirtazapine recommende

Answer 67

28d not renewable AMHP makes application on recommendation of 2 doctors One of the 2 doctors must be Section 12 approved

Answer 68

Admisison for treatment up to 6 months, renewable AMHP and 2 doctors both of whom should have seen patient in last 24

Answer 69

Emergency order in community 72hr assessment order GP, AMHP or NR Often changed to section 2 on hospital arrival

Answer 70

Voluntary patient can be detained by a doctor for 72 hours

Answer 71

As for 5 (2) but nurse for 6 hours

Answer 72

Comminuty treatment order

Answer 73

Court order allowing police to break into a property to remove person to place of safety

Answer 74

someone found in a public place who appears to have a mental disorder can be taken by the police to a Place of Safety Next question

Answer 75

* multiple physical SYMPTOMS present for at least 2 years * patient refuses to accept reassurance or negative test results

Answer 76

persistent belief in the presence of an underlying serious DISEASE, e.g. cancer patient again refuses to accept reassurance or negative test results

Answer 77

typically involves loss of motor or sensory function the patient doesn't consciously feign the symptoms (factitious disorder) or seek material gain (malingering) patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies

Answer 78

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

Answer 79

also known as factitious disorder the intentional production of physical or psychological symptoms

Answer 80

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

Answer 81

10% mortality Occurs with atypical antipsychotics. May also occur with dopaminergic drugs, usually occurs when drug is suddenly stopped or dose reduction More common in young males Onset in first 10d of treatment Pyrexia Rigidity Tachycardia Raised CK and leukocytosis

Answer 82

Stop antipsychotic IV fluids to prevent renal failure Dantrolene in selected cases Bromocriptine (dopamine agonist) may also be used

Answer 83

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)

Answer 84

Extra-pyramidal Increased risk of stroke and VTE in elderly Other side-effects antimuscarinic: dry mouth, blurred vision, urinary retention, constipation sedation, weight gain raised prolactin: galactorrhoea, impaired glucose tolerance neuroleptic malignant syndrome: pyrexia, muscle stiffness reduced seizure threshold (greater with atypicals) prolonged QT interval (particularly haloperidol) Clozapine: agranulocytosis/neutropenia + increased seizure activity

Answer 85

° The longer the period between symptom onset and effective treatment (Duration of Untreated Psychosis), the worse the average outcome. ° The first few years after onset can be particularly distressing with a high risk of suicide. ° Therefore, in many developed countries, specialist Early Intervention in Psychosis teams support people in the first few years of their illness

Answer 86

AEs include weight gain, cardiac arrythmias and DM. Therefore regular monitoring of weight, lipid, glucose profiles + ECGs

Answer 87

If antipsychoic mediacation is stopped

Answer 88

Meical Psychological Social

Answer 89

70% well within a year 80% relapse within 5 years

Answer 90

75% will discontinue within the first 18 months and those that do are 5x more likely to relapse over this period.

Answer 91

Female In relationship, good social support No negative symptoms aDheres to medication Intellgience No stress Good premorbid personality Paranoid subtype Late onset Acute onset No substance misuse Scan normal (CT/MRI)

Answer 92

Young men First few years of illness Persistent hallucinations or delusions History of illicit drugs Previous suicide attempts Lifetime risk in schizophrenics is 10%

Answer 93

Potenital impact on the metabolism, particulalry colazpine and olanzapine whena patient stop smoking

Answer 94

Person is distressed and haqs had a decline in social functioning and: * transient/attenuated psychotic symptoms or * other experiences or behaviour suggestive of possible psychosis * or first-degree relative with psychosis or schizophrenia Refer to specialist assessment for early intervention

Answer 95

CBT +/- family intervention and offer interventions for people with any of the anxiety , depression, emerging personality disorder, or substance misuese **Do not offer antipsychotics**

Answer 96

Oral antipsychotic in conjunction with psychological interventions

Answer 97

Weight gain/DM Akathisia, dyskinesia and dystonia QT prolongation Raised plasma prolactin Unpleasant subjective experiences

Answer 98

Baseline investigations Weight Waist circumference Pulse and BP Fasting blood glucose, HbA1c, lipid profile and prolactin Assessment of movement disorders Assessment of nutritional status, diet and level of physical activity +/- ECG if indicated, either by CV exam or on SPC.

Answer 99

Resposne Side effects ?Movement disorders Weight, 6w, 12w, 1y Waist circumference annualy Pulse and BP at 12w, 1y then annualy FBG and HBA1c at 12w then annualy.

Answer 100

Skin photosensitivity

Answer 101

R/V diagnosis and adherence. Engagement with psychological therapy. Consider other causes of non-response If 2 sequential antipsychotics have been used at appropriate dose (at least 1 of which should ne non-cloazpine-second generation antipsychotic) use clozapine (4-6 week trial of each) If clozapine at opitmised dose does not lead to respond, consider adding a second antipsychotic.

Answer 102

Edinburgh post-natal depression scale \>13/30 indicates a derpessive illness of varying severity

Answer 103

60-70% of women 3-7d post-partum Anxious, tearful and irritable Reassurance and support

Answer 104

10% of women, starts within 1m and peaks at 3m Similar smyptoms to depression Reassurance and support. SSRIs may be used if symptoms are severe. Paroxetine or Sertraline. (Paroxetine has low milk/plasma ratio)

Answer 105

Due to low milk/plasma ratio

Answer 106

0.2% of women 2-3w following birth Severe mood swings and disordered perception (e.g. auditory hallucinations). Admission to hospital Px: 20% risk of recurrence following future pregnancies

Answer 107

Psychotic symptoms: delusions of grandeur, auditory hallucinations

Answer 108

Mood: elevated, irritable Speech and thought: pressured, flight of ideas, poor attention Behaviour: insomnia, loss of inhibitions, increased appetite

Answer 109

Depression

Answer 110

Bradykinesia, tremor and rigidity

Answer 111

Haloperidol or olanzapine NB in PD, all antipsychtoics can aggravate symptoms.

Answer 112

the first SSRI should be withdrawn\* before the alternative SSRI is started

Answer 113

withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low-dose of the alternative SSRI

Answer 114

cross-tapering is recommend (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly) - an exceptions is fluoxetine which should be withdrawn prior to TCAs being started

Answer 115

cross-taper cautiously. Start venlafaxine 37.5 mg daily and increase very slowly

Answer 116

withdraw and then start venlafaxine at 37.5 mg each day and increase very slowly

Answer 117

Low mood, anhedonia, anergia * Reduced concentrationa and ttention * Decreased self-esteem and confience * Guilt/worthlessness * Bleak/pessimisticabout future * Ideas or acts of self-harm * Disturbed sleep * Diminished appetite and weight losee * Psychomotor agitation or retardation * Loss of libido.

Answer 118

At least 2 of the main symptoms and at least 2 of the other symtpoms. None of which should be present to an intense degree \>2w. Should be able to continue work and social functioning

Answer 119

At least 2 of the main 3. And \>3-4 of the other symptoms \>2w Individuals will usually haev considerable difficulty continuing with normal work and social functioning

Answer 120

All 3 of the main +4 of the other which should be of severe intensity. \>2w but if particularly severe, appropriate to make early diagnosis May be evdience of psychosis Individuals show severe distress and or agitation.

Answer 121

'During the last month, have you often been bothered by feeling down, depressed or hopeless?' 'During the last month, have you often been bothered by having little interest or pleasure in doing things?'

Answer 122

All should be for most of the day or nearly every day: * Depressed mood * Anhedonia * Significant weight gain * Insomnia or hypersomnia * Psychomotor agitation or retardation * Fatigue or oloss of energy * Feelings of worhtlessness or excessive or inappropriate guilt * Diminished ability to think or concentrate Recurrent thoughts of death and thoughts about suicide

Answer 123

\>5 symptoms but mild with minor functional impairment

Answer 124

Symptoms or funcitonal impairmeent are between mild and severe

Answer 125

Most symptoms and the symtpoms markedly interfere with functioning. Can occur with or without psychotic symptoms

Answer 126

50% 10-15% 10% 1%

Answer 127

FBC with neutrophil count

Answer 128

* Antipsychotics (predominantly Clozapine) * Antiepileptics * Antithyroid Drugs (Carbimazole) * Antibiotics (Penicillin, Chloramphenicol and Co-Trimoxazole) * Cytotoxic Drugs * Gold * NSAIDs (Naproxen, Indomethacin) * Allopurinol * Mirtazapine

Answer 129

lorazepam or promethazine Olanzopine, quetiapine, risperidone or haloperidol (avoid using more than one) Buccal midazolam can also be used to avoid IM treatment

Answer 130

Lorazepam, promaethazine, aripriprazole, haloperidol Consider IV diazepam

Answer 131

Procylcidine Can also be used for acute dystonia

Answer 132

Propanalol +/- cyproheptadine

Answer 133

May be irreversible but try tetrabenzine

Answer 134

Quitiepine Clozapine Aripriprazole Zotepine Occur at high dosese of olanzapine, amisulpride and risperidone

Answer 135

Aripiprazole, clozapine and quetiapine Olanzapine

Answer 136

Sexual dysfunction (ED, anorgasmia, libido etc)

Answer 137

Minocycline

Answer 138

Aripriprazole and non-clozapine atypicals may worsen psychosis

Answer 139

Tolerance Worry about drinking Eye opener Amnesia Attempts to Cut down \>2= +ve for dependance ?more sensitive than CAGE

Answer 140

Defiance- running away from home Separation anxiety and school refusal Boredom Antisocial behaviour Insomnia (early rather than EMW) Hypersomnia Eating problems

Answer 141

Low mood, anhedonia, anergia

Answer 142

The Self The World The Future Guilt/worthlessness Death or Sucidide Are also common depressive thoughts

Answer 143

Maximal lowering of mood in the morning

Answer 144

Initial anxietry related insomnia Subsequent oversleeping Increased appetite and a relatively bright, reactive mood. More common in adolescence

Answer 145

Nihilistic delusions Hallucinations are usually auditory, in second person and accusing/condemning or urging the individual to commit suicide

Answer 146

Temporal sequence and the basis of thought content (i.e. mood congruent psychosis)

Answer 147

10-20% with rates almost doubled in women Typically in third decade (earlier for bipolar disorder) Strongly associated with socio-economic deprivation

Answer 148

Reduced BDNF which results from hypercortisolaemia (hypo in aypical) and decreased NAdr and 5-HT

Answer 149

High suicide risk Severe derpession Unresponsive to initial treatment Bipolar or recurrent

Answer 150

Mild- CBT Moderate/Severe: CBT + antidepressant

Answer 151

Combining antidepressant with lithium, an atypical or another antidepressant (e.g. mirtazapine)

Answer 152

When an antidepressant is used with a non-antidepressant Combination is two anti-depressants used together

Answer 153

Monitor renal and thyroid function before treatment and every 6 months during treatment (more often if renally impaired) Consider ECG monitoring in those at increased risk of CV disease Monitor [Li] 1w after initiation and each dose change until stable and every 3 months thereafter

Answer 154

Depressive Manic Hypomanic Mixed (both present or rapid alternation)

Answer 155

One or more manic or mixed epsidoes and usually one or more major depressive episodes Recurrent major depressive and hypomanic (BUT NOT MANIC) episodes Chronic mood fluctuations over at least 2 years with epsidoes of depression and hypomania of insufficient severity to meet diagnostic criteria

Answer 156

Alteration in mood: elated and expansive May be characterised by intense irritabilty

Answer 157

Increased psychomotor activity Exagerrated optimism Inflated self-esteem Disinhibtion: sexual, spending, driving, business/religious or political intitiatives. Heightened sensory awareness Rapid thinking and speech: Pressured. Flight of ideas Mania only: mood-congruent delusions and hallucinations (usually auditory) Insight often absent

Answer 158

Early 20s, often starts in childhood and adolescene

Answer 159

Consider stopping antidepressant and offer antipsychotic (regardless of whether the antidepressant is stopped)

Answer 160

Offer atypical (olanzapine, quetiapine, risperidone or haloperidol) If doesn't work consider an alternative from the drugs listed above If alternative not sufficiently effective at the maximum licensed dose off Lithium (if patient refuses Li due to blood monitoring, consider valproate)

Answer 161

Check [plasma] Consider adding haloperidol, onalzapine, quetiapine or risperidone) Consider increasing to maximum livesned dose, if no improvement consider adding one of the above.

Answer 162

Psychological: CBT, interpersonal therapy Pharmacological: If someone develops moderate or severe bipolar depression offer fluoxetine combined with olanzapine or quetiapine on its own Check plasma level, increase if not at maximal. If at maximal add eithe fluoxetine combined with olanazapine or quetiapine on its own Same for VPA

Answer 163

Lithium as first line (if ineffective consider adding VPA) If cannot tolerate Li, switch to VPA or olanzapine

Answer 164

Teratogenic so should ideally be avoided

Answer 165

Seldom respond to lithium, respond bettwer to anti-epileptic mood stabilisers.

Answer 166

30% risk developing full blown BPAD

Answer 167

Torticollois, oculogyric crisis

Answer 168

Strong FHx Gradual onset Low IQ PRemorbid history of social withdrawal Lack of obvious precipitant

Answer 169

Headache Nausea STM impairment Memory loss of events prior to ECT Arrythmias LT: impaired memory In severe depression refractory to medication or those with psychotic symptoms Raised ICP

Answer 170

Extreme restlessness Poor concentration Uncontrolled activity Impulsiveness

Answer 171

Specialist assessment Food diary- ?link with certain foods Methylphenidate (atomoxetine)

Answer 172

Abdo pain Nausea Dyspepsia Growth should be monitored ?Psychaitric disorders should be monitored BP/ pulse every 6 months

Answer 173

Delayed grief: sometimes said to occur when more than 2 weeks passes before grieving begins prolonged grief: difficult to define. Normal grief reactions may take up to and beyond 12 months

Answer 174

symptoms: 6-12 hours seizures: 36 hours delirium tremens: 72 hours

Answer 175

Adjustment disorder: life adversities Grief/abnormal grief reaction: bereavement Acute stress reaction: exceptional stress; can lead to -\> PTSD: exceptional stress

Answer 176

Life adversity e.g. job loss, house move, divorce Onset within weeks, last Symptoms: depression, anxiety, autonomic arousal Practical support: ventilate feelings, problem solving, CBT

Answer 177

Lasts up to 2 years Stages: Denial Anger Guilt Depression Acceptance

Answer 178

Categroised as adjustment disorder Delayed onset, greater intensity and duration More likely when: difficult relationship with deceased, death was sudden, there are constraints to normal grieving

Answer 179

Eceptional stress e.g. accident, war, rape Onset: minutes to hours Lasts Mixed symptoms: dazed/perplexed, intense anxiety Give practical support: reorientate brief CBT

Answer 180

Can be precipitated by acute stress reaction Weeks to months Symptoms \>1m: Intrusive thoughts/flashbacks/nightmares Avoidance Numbing/detachment Increased arousal Trauma focused CBT EMDR Antidepresssants

Answer 181

Dissociative symptoms

Answer 182

Persistent intrsuive thinking/re-experiencing Avoidance Numbing, detachment and enstrangement/loss of interest in significant activites Increased arousal: autonomic symptoms, hypervigilance, ETOH/substance misuse Depression may be comorbid or 2o to PTSD Proportional to magnitude of the stressor. Vulnerability factors: lac of social support, presence of other adversities and pre-morbid personalityy

Answer 183

Mild symptoms: watchful waiting, with 1m follow up PTSD within 3m of event: psychological therapy, drug treatment e.g short term hypnotic Rx. PTSD for \>3m after event: trauma focussed psychological therapy. Rx not first line However: Mitrazapine/Paroxetine for general use. Amitriptyline or phenelzine (mental health specialists) Rx should be offered to PTSD sufferers who cannot start psychological therapy e.g. due to ongoing threat of further trauma eg domestic violence Rx should be offered if comorbid depression/severe hyperarousal Alternative class or adjunctive olanazpine.

Answer 184

Suicide risk Akathisia

Answer 185

Psychological therapy Rx should not be routinely considered

Answer 186

GAD Panic disorders Phobias OCD

Answer 187

Women, younger adults and middle aged Less prevalent in men and the elderly

Answer 188

Reduced GABA Heigthened amydala activation ETOH and BZD may cause attacks

Answer 189

Abuse Separations Demands for high achievement Excessive conformity

Answer 190

Recurrent episodic anxiety attacks which are not restricted to any particular situation. At least 3 panic attacks in a 3 week period for Dx Characteristic symptoms May also develop anticipatory fear.

Answer 191

Autonomic: palpitations, breathlessness, sweating, trembling, breathlessness Feeling of choking Chest pain/discomfort Nausea/abdo pain Dizziness, paraesthesia Chills and hot flushes Derealisation/depersonalisation Fear of losing control

Answer 192

SSRI and CBT TCA where SSRI ineffective BZD not recommended.

Answer 193

Generalised, persistent, excessive anxiety or worry about a number of events that the individual finds difficult to control lasting at least 3 weeks (ICD10) or \>6m (DSM-IV) Usually associated with apprehension, increased vigilance, restlessness, sleep dififculty (initial/middle insomnia, fatigue on waking), motor tension (tremor), autonomic hyperactivity May be comorbid with other anxiety disorders, depression, ETOH and drug abuse

Answer 194

SSRI and CBT SNRI Pregabalin BSD not to be used.

Answer 195

CBT (+/- SSRI) CBT, Rx not first line, SSRI can be used Graded exposure therapy and response prevention. ST BZD eg foor flying can be considered

Answer 196

2-3% prevalence M=F Dx= obsessions and compulsions for \>1h/d for \>2w + distressing impact on life Rx: SSRIs, CBT

Answer 197

Obsessional and compulsive life symptoms but not egodystonic, not resisted

Answer 198

Obsessional preoccpation with imagined or mild phsyical defects

Answer 199

Unwelcome, persistent, recurrent, intrusnive, senseless and uncomfortable to the individual who attempts to suppress them and recognises them as absurd (egodystonic) May be: thoughts, images, impulses, ruminations, doubts Different from volitional fantasies which are not displeasurable (egosyntonic)

Answer 200

Repetitive, purposeful physical or metnal behaviours performed with reluctance in response to an obsessions Carried out in a stereotyped fashion and are designed to neutralise/prevent discomfort Not connected to the trigger in a realistic way Individual realises the behaviour is unreasonable Can include: hand washing, counting, touching and rearranging onjects to achieve symmetry, mental compulsions, hoaridng, arithmomania, onomatomania, folie du pourquoi (irresistable habit of seeking explanations for commonplace facts), inappropriate and excessive tidiness

Answer 201

Anxiety increases until the compulsive activity is performed.

Answer 202

Obsessions and compulsions concerned with contamination Checking compulsions Obsessions without overt compulsive acts Hoarding Depression and abuse of anxiolytics or ETOH.

Answer 203

Paediatric Autoimmune Neuropsychiatric Disrders associated with Streptococci OCD and related disorders occuring suddenly in children following streptococcal infection

Answer 204

CBT (including Exposure Response Prevention) SSRI (fluoxetine, fluvoxamine, paroxetine, sertraline or citalopram) BDD should be fluoxetine (more evidenc) Can be either or dependant on degree of functional impairment and ability to engage in CBT Combination therapy in those with more severe functional impairment Clomipramine should be considered in the treatment of adults with OCD or BDD after an adequate trial of at least one SSRI has been ineffective or poorly tolerated, if the patient prefers clomipramine or has had a previous good response to it. If clomipramine fails can consider additional CBT, adding antipsychotic to SSRI or clomipramine or combinaing clomipramine and citalopram. If combination Rx fails, buspirone. If unable/unwilling to undertake psychological therapy. Rx with SSRI with careful monitoring.

Answer 205

Rigidity of thinking Perfectionsim that may interfere with task completion Preoccupation with rules Objectively high standards are seldom achieved and tendency to hoard Excessive cleanliness and orderliness Emotional coldness Egosyntonic traits

Answer 206

Morbid fear of fatness, distorted body image, delibrate weight loss, amenorrhoea, BMI

Answer 207

Morbid fear of fatness, distorted body image. Craving for good and uncontrolled binge-eating Purging/vomiting/laxative abuse Fluctuating weight (normal/ecessive)

Answer 208

13-20 Men later F:M 3:1

Answer 209

Hypersomna and cogntiive or mood changes Hyperphagia and hypersexuality, Recurrent episodes (1w-1m but resolve spontaneously) KLS is a diagnosis of exclusion Li may be helpful

Answer 210

Syndrome resulting from bilateral lesions of the medial temporal lobe Hyperphagia, hypersexuality, hyperoralitiy, visual agnosia and docility

Answer 211

40% recover 35% improve 20% become chronic 5% death LT risk of osteoporosis

Answer 212

Poor if low BMI, high frequency of purgring 30-40% remission with CBT/IPT

Answer 213

Easting disorder NOS

Answer 214

a morbid fear of fatness ° deliberate weight loss ° distorted body image ° Body Mass Index (BMI, weight [kg]/ht [m]2 ) ° amenorrhoea (primary prepubertally, or secondary; oral contraceptive pill may still cause vaginal bleeds) ° loss of sexual interest and potency in men; in prepubertal boys development will be arrested.

Answer 215

Preoccupation with food Self-consciousness about eating in public Vigorous exercise Constipation Cold intolerance Depressive and OC symtpoms

Answer 216

Emaciation Dry/yellow skin Lanugo hair on the face and trunk Bradycardia and hypotension Anaemia and leucopenia Consequences of repeated vomiting: hypokalaemia, alkalosis, pitted teeth, parotid swelling and scarring of the dorsum of the hand

Answer 217

Scarring of the dorsum of the hand

Answer 218

Do you think you have an eating problem? Do you worry excessively about your weight? NB screen young people with T1DM and poor treatment adherence for the presence of an eating disorder

Answer 219

Psychological intervention: Cognitive analytic therapy (CAT) CBT, interpersonal psychotherapy (IPT), focal psychodynamic therapy and family interventions Rx for comorbid conditions Medication should not be used as sole or primary treatment for AN NB SFx, particulalry cardiac related. Physical managment: 0.5-1kg weight gain in-patient should be aim. Reglar physical montiroing with multi-vitamin supplementation. TPN should not be used in absence of significant GI dysfunction. Moderate to high physical/suicid risk, where patient has not improved despite appropraite out-patient treatment.

Answer 220

1. Self-help programme/SSRI- fluoxetine (60mg/daily, higher than depression) (alternative/additional) 2. CBT (+ other psychological therapy if CBT-BN has not worked), IPT can be offered but takes longer to get resuts. No other pharmacological therapy recommended Physical: Fluid/electrolyte balance

Answer 221

Normal or excessive fluctuant weight Loss of control during bingeing Intense self-loathing and associated depression Multi-impulsive bulimia: ETOH and drug misuse, deliberate self-harm, stealing/sexual disinhbition co-exist

Answer 222

Amenorrhoea Hypokalaemia Signs of excessive vomiting (acute oesophageal tears can occur during forced vomiting)

Answer 223

Activated charcoal N-acetylcysteine Liver transplant

Answer 224

Haemodialysis (urinary alkalinisation

Answer 225

Auditory hallucinations Thought disorders Passivity phenomena Delusional perceptions

Answer 226

Headache Fatigue Anxiety/depression Dizziness

Answer 227

12hrs post-dose 0.4-1mmol/l

Answer 228

6hrs post-dose

Answer 229

Trough levels immediately before dose

Answer 230

Do not need routine monitoring Adjustment of dose, suspected toxicity, detection of non-adherence

Answer 231

Sertraline is the preferred antidepressant following a myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants

Answer 232

Paranoid Schizoid Schizotypal

Answer 233

Borderline (DSM)/ EUPD (ICD) Histrionic [Narcissistic- DSM only] Antisocial (DSM)/ Dissocial (ICD)

Answer 234

Avoidant (DSM)/ Anxious PD Dependent PD Anankastic (DSM)/ OC PD

Answer 235

Cold affect Pervasive distrust and suscpiciousness Preoccupied by mistrust of friends or spouse Bears grudges Reluctance to confide Interprets remarks negatively Hypersensitivity to rejection Grandiose sense of personal rights

Answer 236

Social withdrawal Restricted emotional range Restricted pleasure Lacks confidants Indifference to praise or criticism Aloof Insensitivity to social norms

Answer 237

Pervasive social and interpesronal deficits Ideas of regerence Magical thinking Unusual perception Vague/circumstantial/tangential thinking Inappropriate/constricted affect Eccentricity/suscpiciousness Excessive social anxiety

Answer 238

DSM/ ICD Unstable and intense interpersonal relationships, self image, affect Self-damaging impulsivity: criminal, sex, substance abuse, binge-eating Identity confusion Chronic anhedonia Recurrent suicidal or self-mutilating behaviour Transient Paranoid ideation Frantic efforts to avoid abandonment

Answer 239

Excessive shallow emotionality Attention-seeking Suggestibility Shallow/labile affect Inappropriate sexual seductiveness but immaturity Narcissism Grandiosity Exploitative actions

Answer 240

Pervasie grandiosity Lack of empathy Need for praise

Answer 241

Persistent disregard for rights/safety of others Gross irresponsiblity Incapacity to maintain relatoinships Irritability Low threshold for frustration and aggression Incapacity to experience guilt Deceitfulness Impulsivity Disregard for personal safety Proneness to blame others

Answer 242

Persistent feelings of tension and inadequacy Social inhibitions Unqillingness to become involved with people unless certain of being liked Restriction in lifestyle to maintain physical security

Answer 243

Excessive need to be taken care of Fear of separation Excessive advice to make decisions Difficulty in expressing disagreement Needs others to assume responsiblity Low selflconfidence Undue compliance with others wishes Unwilling to make demands on people Preoccupation with fears of being left alone

Answer 244

Excessive doubt, caution, rigidity and stubborness Preoccupation with details Perfectionism leading to interference with task completion Excessive conscientiousness Excessive pedantry Obsessional thoughts or impulses without resistance

Answer 245

Organic Psychosis Affective Neurosis PD

Answer 246

Adapated CBT, DBT and mentalisation based treatments

Answer 247

Borderline

Answer 248

Paranoid Schizotypal

Answer 249

Disorders of function preference identity

Answer 250

Disorder of sexual preference Can be classifiied into variations of sexual object or variation of sexual act

Answer 251

Delusional misindentification syndrome (psychotic) Belief that a person known to the patient has been replaced by an imposter who is their exact double

Answer 252

Delusional misidentification syndrome (psychotic) Strangers or other people patient meets are the patient's persecutors indisguise Seen in schizophrenia, affective disorders, dementia or other organic illness. Treat the primary disorder. NB Risk

Answer 253

Delusional parasitosis W\>M (2:1) Believe that insects are colonising their body, including skin and eyes. Claim to feel sensations and see bugs. Delusions may be circumscribed or part of a schizophrenic/depressive ilnness Rx Antipsychotics

Answer 254

A delusional belief that is shared by \>2 people of whom only one has a psychotic illness Delusion is usually persecutory or hypochondriacal Principle diagnosis is schizophrenia but may also be affective/dementia

Answer 255

Erotomania Patient has the unfounded and delusional belief that someone is in love with her Patient makes inappropriate advances to the person and becomes angry when rejected May be part of affective (manic) disorder or more rarely schizophrenia. Rx treatment of underlying disease/ antipsychotics

Answer 256

Morbid/pathological jealousy Usually male, convinced partner is being unfaithful. May occur in LT ETOH abuse, dementia, schizophrenia, cocaine addiction and a side effect of dopamine agonism in PD. Risk of violence/homicide

Answer 257

Nihilistic delusions in which ptients believes parts of his or her body are decaying/rotting/don't exist. Patients may also believe they are dead/unable to die Psychotic depression ECT often required due to the severity of the associated depression

Answer 258

Factitous disorder Deliberately feinged symptomatology, usually physical but sometimes psychiatric Multiple presentations to A&E May use multiple aliases, have no fixed GP Characteristically occurs in severe PD

Answer 259

Somatisation Dissociative Undiagnosed illlness

Answer 260

Experience of symptoms resembling pregnancy (abdo swelling, N&V) in expectant fathers Anxietry and psychosomatic symptoms also common

Answer 261

Apporximate, absurd and inconsistent answers to simple questions Clouding of consciousness True/pseudo-hallucinations Somatic symptoms Dissociative disorder against intolerable stress

Answer 262

Substance and type of disorder Acute intoxication Harmful use Dependance Withdrawal state Psychotic disorder Amnesic disorder Residual and late onset psychotic disorders

Answer 263

Compulsion to take Aware of harms but persist Neglect other activities Tolerance Stopping causes withdrawal Time preoccupied with substance Out of control of use Persistent futile wish to cut down`

Answer 264

Craving, flu-like, sweating and yawning, (24-48h) Mydriasis, abdo pain, diarrhoea, agitation, restlessness, piloerection and tachycardia occur later (7-10d)

Answer 265

Methadone (agonist)/ buprenorphine (partial agonist) are first line Lofexidine sometimes used for short detox treatments Naltrexone used to prevent relapse Naloxone used for OD

Answer 266

Learning points : •Answer : C . Contrast acute EPSE’s (Parkinsonism, acute dystonias etc) to chronic side effects like TD. Tardive dyskinesias (TDs) are involuntary movements of the tongue, lips, face, trunk, and extremities that occur in patients exposed to long-term dopaminergic antagonists (commonly first generation antipsychotics ). Note that even a single exposure to a dopamine antagonist in people with brain disorders i.e. LD or fetal alcohol syndrome can precipitate it. Older patients and women with chronic psychotic illness are particularly susceptible.

Answer 267

Learning points : * Answer : A. Akathisia is most commonly experienced in the first few weeks of treatment then generally reduces in intensity or wears out completely. In a minority, it starts later on in treatment cycle. * may also be involved with disrupted NMDA channel * increased levels of the neurotransmitter norepinephrine • * Propranolol * Clonazepam

Answer 268

•Answer is D. On the basis of this history, vascular dementia is a concern, though delirium must be excluded first. The evidence for using anticholinesterases for VD is reasonable (despite what NICE say) , in practice differentiating VD from Alzheimer’s is quite tough .This gentleman needs to minimise his cardiovascular risk factors as a first line of treatment by addressing his smoking, concordance and diabetic management.

Answer 269

Answer is H. The slowed thoughts and movements, lethargy , weight gain , self neglect could all suggest depression with atypical features, but in the context of her medical history, hypothyroidism should be excluded as cause of her affective and cognitive symptoms. If her TFTs are normal, atypical depression would be the next diagnosis to consider.

Answer 270

•Answer is E. This is likely to be Dementia with Lewy Bodies (suggested by new parkinsonian signs, vivid visual hallucinations). Acetylcholinesterase inhibitors are used in both DLB and Alzheimer's disease. Revise the presenting features of DLB. The full Parkinson’s syndrome is tremor, rigidity , bradykinesia and postural instability. • •There is eveidence for Donepezil’s benefit in these patients: Donepezil for Dementia with Lewy Bodies: A Randomized, Placebo-Controlled Trial, Ann Neurol. Jul 2012; 72: 41–52.

Answer 271

1.An 18 year-old man has a Hx of shallow affect, mannerisms, multiple somatic complaints and incoherent speech. He is withdrawn and describes hearing multiple voices B 2.A 40 year-old woman has been on an antipsychotic for 7 months. Her delusions and hallucinations have resolved. She has developed low mood, feelings of hopelessness and low energy levels for the last six weeks. E 3. A 24 year-old man has a 6 month Hx of talking and laughing to himself. he hears voices talking to him and neglects his personal hygiene. He is uncommunicative most of the time. He has also damaged property and assaulted strangers for no apparent reason. Often he assumes uncomfortable postures for hours. A

Answer 272

1.50 year-old male has developed rapidly progressing dementia for the last 30months which is associated with tremor, rigidity, myoclonus and triphasic waves on the EEG. A 2.55 year-old woman has a slow progressive dementia of 9 years duration with choreiform movements of the face and hands and has abnormal gait. There is a positive family history of the same. C 3. 60 year-old man has a Hx of impaired cognitive functions that are unevenly impaired associated with Hx of hypertension, emotional lability and transient episodes of delirium. F

Answer 273

Acute intoxication Alcohol withdrawal Alcohol dependance Psychotic disorders (alcoholic hallucinations, jealousy) Amnesiv syndrome Residual and late onset disorders: include depression and dementia

Answer 274

Compulsion/strong desire to drink Aware of physical/psychological harms Neglect of other activites Tolerance Stopping causes withdrawal Stereotyped pattern of drinking Time preoccupied with alcohol Out of control use Persistent, futile wish to cut down.

Answer 275

Cut down Annoyed by suggesting you do so Guilty about drinking Eye-opener

Answer 276

\>2= hazardous drinking

Answer 277

Confusion Ataxia Opthlamoplegia

Answer 278

Profound anterograde STM loss Confabulation

Answer 279

Acute detoxiciation: tapering chlordiazepoxide/diazepam Delerium tremens treated with lorazepam or antipschotics Rehydration, correction of electrolye disturbance and oral/parenteral thiamine Motivational; interiewing, psychological therapies, self-help groups Disulfiram: increased acetaldehyde accunulation Acamprosate: acts on GABA to reduce cravings and risk of relapse

Answer 280

Clozapine: reduces overall mortality from schizophrenia due to reduction in the rate of suicide.

Answer 281

D2/D3 antagonists. (Aripriprazole is a partial D2 agonist, full binding decreases dopamine availability by 30%. Most atypicals are also potent 5hT-2A antagonists

Answer 282

D2/D3. Also potent antagonists at cholinergic, adrenergic and histaminergic Rs.

Answer 283

Risperidone, olanzapine and quetiapine

Answer 284

Haloperiodl in combination with a BZD

Answer 285

Cardiac: prolonged QTc Dry mouth, urinary retention, constipation, confusion Sedation Postural hypotension AND: Neuroleptic malignant syndrome

Answer 286

Hyperpyrexia Autonomic instability/confusion Hypertonia Raised serum CK

Answer 287

Weight gain, impaired GT, dyslipidaemia Clozapine: hypersalivation, constipation, hypo/HTN, weight gain, fever, nausea, noctuneral enuresis Seizures. Agranulocytosis

Answer 288

Movement disorders: parkinsonism, akathisia Acute dystonic reactions: torticollis, oculogyric crisis Tardive dyskinesia Hyperprolactinaemia: amenorrhea, galactorrheoa, sexual dysfunction, increased risk of breast cancer Blood dyscrasias Retinal pgimentation Photosensitvity Cholestatic jaundice

Answer 289

Procyclidinge. Reflect drug-induced dopamine/acetylcholine imbalance

Answer 290

Beta blockers BZD

Answer 291

Irreversible in 50% Clozapine may treat tardive dyskinesia as well as psychosis

Answer 292

98% relapse if discontinue after 2 years If patients discontinue medication, taper over at least 3 weeks as stopping suddenly doubles the relapse risk.

Answer 293

BMI ECG Blood tests: FBC, U&E, lipids, LFT, glucose, prolactin

Answer 294

Headache Anorexia Nausea Indigestion Anxiety Sexual dysfunction Increased suicidal ideation (not recommended Withdrawal syndrome

Answer 295

GI bleeding Hyponatraemia in older?

Answer 296

HTN/hypotension Cardiotoxic in OD?

Answer 297

NSST (noradrenergic and specific serotonergic antidepressant) Dry mouth, drowsiness and weight gain?

Answer 298

Amitriptyline, dothiepine, imipramine, lofepramine Anticholinergic, antiadrenergic, cardiac arrhythmia, seizures

Answer 299

Phenelzine, tranylcypromine Anticholinergic, antiadrenergic, tyramine reaction

Answer 300

Agomelatine N, diarrhoea, constipation abdo pain Increased serum transaminases Headache, dizziness, drowsiness, anxiety, insomnia, fatigue Back pain, sweating

Answer 301

Age? Time? Year? Where are we? Who am I, who is that? Remember this address: 42 West Street (recall at end) What is your date of birth? Who is the prime minister? When did the 2nd world war end? Can you count down from 20 to 1? 7-8/10: impairment

Answer 302

Current behavioural/emotional difficulty School behaviour and academic perfromance Daily routine Family structure and function Look for signs of abuse or neglect

Answer 303

Chil: Low birthweight, intellectual or physical impairment, persistently restless or crying Parents: Young/single, disadvantaged, isolated, own history of abuse, didn't want child, unrealistic discipline

Answer 304

Unexplained injuries Age inappropriate sexual talk/behaviour, secondary enuresis, STI, nightmares Withdrawal/fearful of parents, failure to thrive

Answer 305

Childhood: emotional, conduct, developmental disorders Adulthood: depression, PD, conversion disorders, deliberate self harm, child-rearing problems

Answer 306

Report suspicions to UK social services Involve police if neede Individual/family therapy

Answer 307

Hyperkinetic disorders Conduct: socialised, unsocialised, oppositional defiant Emotional: separation anxiety, social anxiety, sibling rivalry disorder Social functioning: Elective mutism, reactive attachment disorder Other: enuresis, encopresis

Answer 308

Pervasive developmental: autism, asperger's, childhood disintegrative disorder Specific developmental disorder

Answer 309

Depression Anxiety: phobias, OCD Adjustment: bereavement Psychotic Sleep problems

Answer 310

Core symptoms present for at least 6 months: Short attention span Distractibility Overactivity Impulsivity Almost always present by age 7 and present in at least two settings (home/school)

Answer 311

Conduct disorder Anxiety/depression Language delay Specific reading retardation Antisocial behaviour Clumsiness Comorbidity has a poorer prognosis (those with comorbid conduct disorde are at particular risk of substance disorders in adolescence)

Answer 312

Genetic loading Social adversity Parental ETOH abuse Dietary constituents Tranquiliser exposure

Answer 313

Parent-training/education problems are first line, drugs not recommended. Group-based parent training/education usually first line. May include CBT/social skills training. Individual psychological therapy may be more appropriate in older children. Drug treatment next line (reserved for those with severe symptoms and moderate levels of impairment) Drug treatment first line. (if refused- group-parent training/education. Methylphenidate, atomoxetine or dexamfetamine

Answer 314

History of: syncope, breathlessness and other CV symptoms HR and BP Height and weight FHx of CVD and CV exam (ECG if FHx of CVD/sudden death) (Risk assessment for substance misuse)

Answer 315

ADHD without significant comorbidity/conduct disorder

Answer 316

When tics/tourette's, anxiety, substance misues or stimulat diversion are present

Answer 317

Atomoxetine 6 weeks

Answer 318

Methylphenidate If control inadequate/symptoms persist consider second line/CBT if there is persistnet functional impairment

Answer 319

Socialised: viewed as normal within peer group or family Unsocialised: solitary with peer and parental rejection

Answer 320

Group/individual parent-training/education programmes CBT and social skills therapies may target child's aggressive behaviours or poor social interactions

Answer 321

Characterised by persistent, angry and defiant behaviours Similar but withoutsevere aggressive or dissocial acts

Answer 322

Fluoxetine may be prescribed cautiously

Answer 323

5-6y: separation anxiety 10-11y: school transition Adolescents: low self-esteem and depression

Answer 324

Non-organic, involuntary bladder emptying after the age of 5 Secondary if there had been a period of urinary continence

Answer 325

Exclusion of physical pathology (UTI) Addressing excessive or insufficient fluid intake or abnormal toilating patterns Reward system for adherence to programme rather than dryness Enuresis alarms: sense moisture and alert child of need to go Rx: desmopressin (synthetic ADH) or imipramine (TCA)

Answer 326

Deposition of stool in inappropriate places in the presence of normal bowel control. Voluntary faecal retention with subsequent overflow is present in some cases

Answer 327

Exclude organic causes e.g. Hirschprung's or pain on defecation Treatment aims to restore normal bowel habits and restore normal parental child relationships. Parents encouraged to ignore soiling and not punish child.

Answer 328

Pervasive failure to make social relationshipships (aloofness, lack of eye contact, poor empathy) Major difficulties with verbal and non-verbal communication/language development. Resistance to change with associated ritualistic and or manneristic behaviours. Inappropriate attachments to unusual objects, restricted range of interests, stereotyped behaviours, unpredictable outbusts 95% have IQ

Answer 329

LD, deafness and childhood schizophrenia

Answer 330

Fragile X Tuberous sclerosis Perinatal complications

Answer 331

Specialist, intensive behavioural treatments (\>25 hours a week) Family support and counselling Consider antipsychotic medication for managing behaviour that challenges in children and young people with autism when psychosocial or other interventions are insufficient or could not be delivered because of the severity of the behaviour. Start low and slow

Answer 332

Characterised by normal initial development and the subsequent onset of a dementia with socail, language and motor regression with prominent stereotypes. Aetiology includes infections (especially subacute sclerosing panencephalitis) and neurometabolic disorders

Answer 333

May be acute in onset (better prognosis) or have a prodroe of apparent developmental delay. As in adulthood, presentation is with hallucinations, delusions and thought disorder but with a greater preoponderance of motor disturbance (particulalry catatonia). Antipsychotics are the mainstay NB INCREASED RISK OF WEIGHT GAIN AND METABOLIC SYNDROME.

Answer 334

Skin photosensitivity, advise using sunscreen

Answer 335

Emotional upset, identiy issues, conflict with parents, delinquent behaviour and poor school performance Comorbidity is even more common than in adults

Answer 336

Psychosocial intervention should be first line Medciation may be used cautiously if problems are severe: Atypcial antipschotics (risperidone) may reduce aggressive behaviour, especially in the context of coexisiting PDD (e.g. autism) SSRI may reduce impulsivity, irritability and lability of mood

Answer 337

Family therapy Individual psychotherpay (particulalry CBT) Antidepressants, only fluoxetine is generally recommended due to increase in risk of suicidal thoughts and self-harm in young people on SSRIs

Answer 338

Late adolescence Deteriorating school pefromance Similar clinical presentation Bizarre behaviour, social withdrawal and anxiety, fleeting first rank symptoms

Answer 339

Organic states, mood disorder, drug-induced psychosis, adolescent crises and schizoid personality

Answer 340

Prophylaxis in recurrent affective disorder Acute treatment of mania Augmentation of antidepressants in resistant depression Schizoaffective illness Control of aggression

Answer 341

Unknown Interacts with biological systems in which sodium, K, Ca or Mg involved At therapeutic blood levels it has effects on neurotransmission Its interference with cAMP linked receptors explains it action on the thyroid and kidney

Answer 342

0.4-1mmol/l Thyorid and renal function prior to starting and every 6 months whilst taking it Serum Li levels initially weekly, therafter every 12 weeks. Bloods taken 12 hours after last dose

Answer 343

nausea fine tremor weight gain oedema polydipsia and polyuira exacerbation ofpsoriasis and acne Hypothyroidism

Answer 344

\>1mmol/l Vomiting Diarrhoea Coarse tremor Slurred speech Ataxia Drowsiness and confusion Convlusions and coma

Answer 345

Fluid therapy to restore GFR

Answer 346

Should be avoided in renal, cardiac, thyroid and Addison's disease

Answer 347

Dehydration and diuretics NSAIDs, CCV and some antibiotics

Answer 348

Carbamezapine, litihum and valproic acid are teratogenic nd should be avoided during pregnancy (especially first trimester) and lactation May affect metabolism of other drugs including OCP necessitating other contraceptive precautions

Answer 349

Valproic acid (sodium valproate) and carbemazepine

Answer 350

Nausea Drowsiness Dizziness Blood dyscrasia (monitor FBC every 6 months and warn that unexplained sore throat may herald agranulocytosis)

Answer 351

Nausea Gastric irritation Diarrhoea Weight gain

Answer 352

Anxiolytic, sleep inducing, anticonvulsant and muscle relaxants Insomnia ST use in GAD but not phobias or panic disorders Alcohol withdrawal states Control of violent behaviour Also used as 2nd line drugs in refractory epilepsy

Answer 353

Hypnotics without anticonvulsant or msucle relaxing properties

Answer 354

Diazepam, chlordiazepoxide, nitrazepam Lorazepam, oxazepam and temazepam

Answer 355

Potentiate the inhibitory effects of GABA Buspirone is a 5HT1a partial agonist

Answer 356

Drowsiness Ataxia Amnesia Dependance Disinbinition Ptoetniate alcohol and other sedatives

Answer 357

Respiratory depression Drowsiness Dysarthria and ataxia Flumazenil- a selective BZD antagonist (can be hazardous in mixed OD e.g. with TCA or in BZD-dependant patients)

Answer 358

Marked anxiety Shakiness Abdo cramps Perceptual disturbance Persecutory delusions Seizures

Answer 359

Decreased appetite and weight loss Anxiety Agitation Insomnia

Answer 360

Cholinesterase inhibitors: donepezil, rivastigmine and galantamine Glutamate antagonist: memantine Rivastigmine can be fiven as a transdermal patch

Answer 361

GI: ND anorexia Dizziness, syncope, bradycardia Rash Muscle cramps Urinary incontinence (and potentially retention)

Answer 362

Constipation HTN Dyspnoea Headache Dizziness Drowsiness

Answer 363

Chromosome 21 95% trisomy 5% translocation

Answer 364

X linked dominant condition. accounts for 8% of males with LD M\>F

Answer 365

Flat occiput Oblique palpebral fissures Small mouth High arched palate Broad hands, single transverse palmar crease 50% have caridac septal defects 15% have mild LD, other moderate or severe 5% have autistic traits Alzheimers develops after age 50 Hypothyroidism

Answer 366

Most males and a third affected females have LD 15-55% have autism Large head and ears Poor eye contact Abnormal sppech Hypersensitivity to touch, auditory, visual stimuli Hand flapping Hand biting

Answer 367

DS and Fragile X

Answer 368

Low intellectual performance Onset at birth or in early childhood Reduced lifeskills

Answer 369

Chromosomal: DS X-linked: Fragile X, Lesch Nyhan AD: Tuberose scelrosis, neurofibromatosis AR: usually metabolic disorders e.g. PKU Autism is usually associated with LD

Answer 370

Infective: toxoplasma, rubella and CMV Hypoxic or toxic or related to maternal disease

Answer 371

Prematurity, hypoxia, intracerebral bleed

Answer 372

Infection, injury, malnutirtion, hormonal, metabolic, toxic, epileptic

Answer 373

Mild: 50-70 80% Moderate: 35-49 %12 Severe: 20-34 %7 Profound

Answer 374

Mild is usually due to limited social/learning opportunities and genetic low IQ Moderate-Profound LD is more typically associated with a specific biological cause

Answer 375

MIld: can live independently and have employment May have difficulty coping with stress and more complex social functioning. Moderate: usually need supported accomodation Severe-Profound, very limited skills

Answer 376

Mild: slight or absent, 6% have epilepsy Moderate: Limited but useful language Severe-Profuound: very limited language, 1/3rd have epilepsy, 10% incontinent, 15% cannot walk

Answer 377

Increased in people with LD Genetic, organic (esp. epilepsy), psychological and social factors eg stigma

Answer 378

Diagnostic overshadowing

Answer 379

Behavioural disorder (increases with severity of LD) Depression (diagnosis relies on motor or and behavioural changes rather than verbal expressions of distress) Anxiety disorders (eg. OCD and phobias) Dissociative symptoms Schizophrenia (3% prevalence in LD, presents with simple and repetitive hallucinations and unelaborated, usually persecutory delusions Mania: usually presents as overly irritable behaviour

Answer 380

A communication system used in LD using signs and gestures

Answer 381

10% More common in those with, PPHx, conflicting feelings about the pregnancy, a history of sexual abuse as a child, USS showing fetal anomalies Only increased if prophylactic medication is stopped, e.g due to teratogenicity. Substance misuse decreases, suicide also decreases (those that occur often associated with substance misuse)

Answer 382

First 10 days postpartum, 50-70% of delivers Symptoms: emotional lability, crying, irritability and worries about coping with the baby Self-limiting but severe blues increases risk of depression No intervention required apart from reassurance although if symptoms persist, assess for depression

Answer 383

Cllinical features for depression but incudes guilt and anxiety re baby feelings of inadequate mothering unreasonable fears for the baby's health reluctance to hold/feed the baby thoughts of harming the baby. Can persist for a year or more

Answer 384

Mother: Hx of depression, low monthly income, no post-16 education, unemployment Relationships: unmarried, relationship dissatisfaction, domestic violence, few confiding relationships Baby: premature, severe cardiac defects, multiple births

Answer 385

Metabolic syndrome/gestational diabetes

Answer 386

Facilitated self help

Answer 387

Conisder, TCA, SSRI or SNRI

Answer 388

High intensity psychological intervention i.e. CBT TCA/SSRI/SNRI

Answer 389

Stopping medication gradually Continuing medication if she understands risk Chaning medication Combining medication with a high intensity psychological intervention

Answer 390

Offer antipsychotic

Answer 391

Offer antipsychotic if she is stopping lithium or plans to breastfeed. Consider psychological intervention

Answer 392

Increased risk of teratogenicity, we are not sure of degree of risk

Answer 393

Usually hospitalisation, should be with baby to a specialist mother-and-baby unit Treatment is usually with antipsychotics ST prognosis is excellent

Answer 394

Should be advised to time feeds to avoid peak drug levels in milk and how to recognise ADRs in child

Answer 395

TCAs have lower known risks during pregnancy however most have a higher fatal toxicity index than SSRIs Sertraline has the lowest known risk during pregnancy (avoid paroxetine as associated with fetal heart defects and neonatal pulmonary HTN), SSRIs are associated with a neonatal behavioural syndrome

Answer 396

Imipramine, nortiptyline and sertraline are present in breast milk and relatively low levles. Citalopram and fluoxetine at relatively high levels

Answer 397

Typical antipsychotics e.g. haloperiodl, chlorpromazine or trifluoperazine

Answer 398

Cleft palate and other fetal malformations

Answer 399

Symptoms include low mood, insomnia, poor concentration, irritability, poor impulse control, food craving and physical complaints Onset after ovulation with rapid relief within 24 hours of the onset of menstrual flow.

Answer 400

Disturbed sleep Multiple physical problems for which there is no obvious cause Motor disturbance Dependancy having been previously independant

Answer 401

SSRI, (TCA shouldn't be started in primary care, although amitryptilline often prescribed for those with chronic pain, shoulnd't coprescribe SSRI and TCA) Mirtazepine is useful when poor sleep and anxiety and main symptoms Psychological therapies Physical activity e.g exercise Psycho-social interventions

Answer 402

Due to risk of postural hypotension and subsequent falls

Answer 403

There is some evidence that antidepressants are not effective in dementia, so consider other treatment first unless severe depression/risk of suicide

Answer 404

Trial SSRI for 4 weeks, if inadequate resposne consider switching to alternative class. NB can take up to 8 weeks to have an effect. Lithium augmentation is effective in some patients with refractory depression ECT is very effective in more severe depression, particulalry in patients with delusions, psychomotor retardatio or those refusing food or fluid in whom the risk of irreversible physical deterioriation is high

Answer 405

Depression doubles mortality rate due to increased medical morbidity and increased risk of suicide Prognosis improves with early intervention, there is high risk of chronicity and of relapse. Secondary prevention, i.e. continuing antidepressant therapy to prevent relapse is highly effective

Answer 406

Precipitated by acute physical illness such as stroke

Answer 407

1/10 of new onset mania in \>60. Overt elation tends to be less present although patient has grandiose ideation. The clinical picture more commonly consists of irritability, lability of mood and perplexity, much like deleirum but distinguishable by clear consciousness

Answer 408

Antipsychotics effective as acute treatment and some, e.g. Olanzapine are effective at preventing relapse. Atypicals should be used with caution due to increased risk of VTE or stroke Lithium may also be used although 25% of older people develop neurotoxicity (particulalry in those with PD or dementia), therapeutic and toxic levels may be lower

Answer 409

40-60= late onset \>60= very late onset

Answer 410

Genetic component Sensory deprivation eg deafness Social isolation Brain imaging abnormalities Organic brain disease

Answer 411

At incresed risk for tardive dyskinesia

Answer 412

\>2 years of multip[le physical symptoms with no physical explanation GI and skin complaints are the most common W\>\>M

Answer 413

Non-epileptic seizures (NB can co-iccur with epileptic seizures)

Answer 414

Rare dissociative disorder Nonsensical or wrong answers to questions or doing things incorrectly, other dissociative symptoms such as fugue, amnesia or conversion disorder, often with visual pseudohallucinations and a decreased state of consciousness Reaction to extreme stress although can be grouped with fictitious disorders

Answer 415

Fluctuating symptoms Localised specific cognitive deficits Associated neurological signs Vague or transient paranoid delusions Olfactory or visual hallucinations Untypical symptoms of a functional disorder Record of cognitive disorder before other psychiatric symptoms

Answer 416

Disturbance of consciousness Amnesia Behavioural disorders

Answer 417

Longer duration of post-traumatic amnesia (loss of memories about the injury and subsequent events)- more accurate than retrograde amneisa Duration of LOC \>24h

Answer 418

Direct neurophysiological effects e.g. cognitive disorders, temporal lobe injuries and psychosis. Psychosocial impact of sudden disbility-\> anxiety and depression Lability of mood and apathy may be particulalry prominent

Answer 419

Personlaity and behavioural changes Depression and anxiety Cognitive disorders Psychiatric disorders

Answer 420

Frtonal lobe injury: disinhibition, aggression, impullsivity, apathy Catastrophic reactions: bursts of aggression, anxiety, crying and uncontrolled crying or laughing (20% post stroke)

Answer 421

Punch drunk syndrome: e.g. in boxers Vascular dementia from CVA Chrnic cognitive impairment: visuospatial neglect, impaired learning, decreased attention, apraxia

Answer 422

Punch drunk syndrome Chronic traumatic encephalopathy: neurodegenterative disease with features of dementia. Symptoms include dementia, problems with memory, ataxia, parkinsonism May be prone to inappropriate or explosive behaviour

Answer 423

BPAD: especially rapidly cycling which is increased after TBI Psyhcosis common after temporal lobe injury

Answer 424

Depression in 1/3 Anxiety in 1/4 Increased risk of suicide (5% after TBI)

Answer 425

Anxiety, irritability, insomnia, reduced concentration, depression, emotional lability, hypersensitivity to noise/light, chronic tiredness. Maybe organic basis No specific treatment

Answer 426

0.5-1% M\>F Onset Most common type is complex focal Present in 25% of people with LD

Answer 427

Cerebrovascular disease (15%) Cerebral tumours (6%) Alcohol related seizures (6%) Post-traumatic seizures

Answer 428

Pre-ictal: depression can occur, psychosis rare Ictal: depression can occur, psychosis rarely occurs as part of simple, partial, complex parital or absence seizures Post-ictal: depression is relatively common, psychosis in 6-10% with intractable epilepsy, begins months Inter-ictal (disturbances are chronic and not related to the ictal electrial discharge): depression very common, psychosis can develop in those with recurrent post-ictal episodes, usually associated with temporal lobe epilepsy, symptoms very similar to schizophrenia

Answer 429

Affects 30-50% of people with epilepsy at some point Aetiology includes: demoralisation/stigma, possibly lesion location, anti-epileptic drugs (phenobarbitone and vigabatrin, FHx of depression), adverse life effents Depression can indirectly increase seizure frequency through the mechanism of sleep deprivation. Careful Rx with antidepressants, SNRIs and SSRIs are recommended as lower seizure threshold. ECT if necessary Carbamezapine and lamotrigine are anti-epileptic agents that may also improve mood

Answer 430

Citalopram as it is least likely to interact with anti-epilepsy drugs

Answer 431

Most common form of pschosis in epilepsy Should be distinguished from delerium Can occur up to a week after seizure. Symptoms include delusions, depressive or mani psychhosis, bizarre thoughts and behaviour, visual hallucinations are common.

Answer 432

Rx with antipsychotis, preferably those with least effect on seizure threshold e.g. sulpiride and haloperiodl

Answer 433

AKA dissociative convulsions Can simulatem real seizures and occur in 20-30% of people with chronic treatment-resistant epilepsy Frequent, occur when other people are present, have an emotional precipitant, associated with a history of childhood sexual abuse EEG is normal during the attack

Answer 434

Cognitive deficits, dementia (demyleniation) Depression (stress rather than disease process, or drug treatment: steroids, baclofen, beta interferon) Mania: disease process, drugs e.g. steroids, baclofen Euphoria/elation, emotional lability, pathological laughing/crying: disease process Affective disorders increased but nonaffective psychosis is no more common. Those with psychosis are more likely to have plaques in bilateral temporal horn areas

Answer 435

Cognitive impairments: disease process, usually acute confusional states (due to CNS vasculitis/encephalopathy Depression: psychoscoial stress, disease process, iatrogenic (e.g. steroids) Psychosis uncommon

Answer 436

Deficient striatal dopaminergic activity

Answer 437

Depression and anxiety (40%): diease process (dopaminergic, serotonergic, cholinergic limbic pathway dysfunction), psychosocial factors Dementia (30%): disease process Other cognitive impairments: disease process, iatrogenic or related to depression Psychosis (25%): iatrogenic, disease process Apathy (40%): disease process Impulsivity (

Answer 438

Visual hallucinations and persectuory delusions, sometimes with pathological jealousy. More common in people with cognitive impairment and on increasing antiparkinsonian medication

Answer 439

Drugs with a relatively low risk of extrapyramidal SEs e.g. quetiapine citalopram

Answer 440

Cerebral atrophy and reduced GABA resulting in dopamine hypersensitivity. Songitive impariments usually progress to subcortical dementia. Psychiatric disturbances are common in HD. Depression can preced other symptoms Increased risk of suicide ( Treatment is symptomatic and dpression and psychoses should be treated with standard medications. Atypicals preferred due to reduced impact on motor symptoms

Answer 441

Wilson's Disease Cognitive impairments that usually progress to subcortical dementia (disease process) Irritablity/aggresion (inability to communicate, executive dysfunction Apathy: iatrogenic, depression Depression: psychosocial stress, disease process Mania and psychosis: disease process

Answer 442

Excess Cu deposition in the lenticular nuclei (autosomal recessive) Penicillamine

Answer 443

Excessive daytime sleepiness, cataplexy, sleep paralysis, hypnogogic hallucinations Methylphenidate or modafinil

Answer 444

Individuals act out dreams due to lack of atonia during rem sleep Treatment with clonazepam and making sleep environment safe Can be idiopathic or associated with PD, LBD or GB

Answer 445

Involunatry swearing Involuntary rude sign

Answer 446

Stereotypy: involuntary patterned, coordinated repetitive, rhythmic and nonreflexive features. Tend to occur in clusters and are asoociated with periods of stress, excitement fatigue or boredom- suppressible Mannerism: odd, idiosyncratic METHOD OF PERFORMING A TASK that is unique to an individual and serves no apparent function (ie, a person who cocks an arm in a peculiar way in order to drink from a cup; a ballplayer who performs ritualistic acts "for luck."). Note that stereotypies have no function/purpose while mannerisms are a purposeful movement.

Answer 447

Psychoeducation Medication: antipsychotics for tics, clonidine +/- stimulants for ADHD Behavioural therapy

Answer 448

HIV increases the likelihood of psychiatric illness e.g. crises following diagnoses Impulsive behaviour associated with some mental illnesses may lead to HIV infection

Answer 449

Depression is common at all stages. Dx may be difficult: apathy and fatigue may be due to retroviral therapy. Fatigue and weight loss may be due to progression/decline in CD4 count/ AIDS-related dementia may also present as a depression like illness. Occurs with a very low CD4 count, thought to be a direct manifestation of HIV infection in the brain. Opportunistic infections may also contribute to the dementia syndrome

Answer 450

Herpes simplex Presentation ussually with severe headache, vomiting and reduced consciousness but occasionally can present with psychosis, seizures of delerium. At least 50% of survivors experience disturbed behaviour, concentration or social adjustment. Some with chronic cognitive impairment

Answer 451

General paralysis of the insane: personality changes (disinhibition, irritability, lability), cogntive changes (poor concentration), dementia, depression, grandiosity and rarely mania and schizophrenic-like psychoses. VDRL IM penicllin

Answer 452

Rapidly fatal dementia associated with myoclonic jerks. sCJD presents with physical symptoms vCJD presents more frequently with psychiatric symptoms (mood swings, fatigue, social withdrawal)

Answer 453

Clinical presentation may be abdominal or neurological. Psychiatric distrubances can include delerium, depression, emotional lability and schizophrenia like psychoses.

Answer 454

Pernicious anaemia which may be accompanied by subacute degenration of the spinal cord Psychiatric symptoms include slowing of mental processes, confusion, memory problems, intellectual impairment, depression and paranoid delusions

Answer 455

Anxiety/depression Irritability, apathy and poor appetite in older people Psychotic depression reported N/A

Answer 456

Depression/anxiety Acute aitation Hallucinations Dementia/delerium

Answer 457

Depression apathy/emotional lability Hallucinations occasionally reported after parathyroidectomy Occasionally memory deficits, poor concentration, cognitive impairment, delerium after parathyroidectomy

Answer 458

Depression, mania

Answer 459

Depression, apathy

Answer 460

Depression, iritability, impaired memory

Answer 461

Episodic anxiety

Answer 462

Impaired consciousness and attention + perceptual disturbance (usually visual hallucinations or distortions of perception (macro/micropsia) or cognitive disturbance (decreased concentration, memory, orientation, thinking slow or muddled, distractible with incoherent/difficult to follow speech) + Developed over short period of time and fluctuant (often worse at night) + Evidence it may be related to a physical cause

Answer 463

Hypoactive Hyperactive Mixed Mood and affect may fluctate and may be accompanied by irritability/perplexity or apathy and depression Transient delusions are common, may be secondary to abnromal perceptions and often persecutory with associated ideas of reference. Sleep/wake cycle distrubance

Answer 464

\>65 y/o People with diffuse brain disease e.g. demetnia People with current hip fracture Severely ill

Answer 465

Difficult to distinguish from LBD in which cognition typically fluctuates Functional psychiatric conditions (mania, depression and late-onset schizophrenia) Response to major stress Dissociative disorders

Answer 466

Rapid vs slow Fluctuant vs progressive Clouded vs alert consciousness Vivid complex and muddled thought content vs impoversihed Hallucinations very common and predominantly visual vs auditory or visual in 1/3

Answer 467

Drugs Eyes, ears and other sensory deficits Low O2 states (i.e. heart attack, stroke and PE) Infection Retention of urine/stool Ictal state Underhydration/undernutrition Metabolic causes (DM, post-operative state, Na abnrormalities) Subdural haematoma

Answer 468

Infection: HIV, sepsis, pneumonia Withdrawal: ETOH, barbiturate, sedative-hypnotic Acute metabolic: acidosis, alkalosis, electrolyte disturbance, hepatic failure, renal failure Traemua: closed-head injury, heat stroke, postoperative, severe burns CNS pathology: Abscess, haemorrhage, hydrocephalus, SDH, infection, seizures, stroke, tunmours Hypoxia: Anaemia, CO poisoning, hypoTN, pulmonary or cardiac failure Deficiencies: B12, folate, niacin, thiamine Endocrinopathies, hyper/hypoadrenocorticism, hyper/hypoglycaemia, myxoedema, hyperPTH Acute vascular: hypertensive encephalopathy, stroke, arrythmia, shock Toxins/drugs: prescription durgs, illicit drugs, pesticides, solvents Heavy metals: lead, Mn, mercury

Answer 469

Collateral history: premorbid level of function MSE Physical examination, focal neurology Breathalyser MSU, pregnancy test, urine drug screen CXR CT/MRI Head Bloods: FBC: anaemia, macrocytosis, leucocytosis ESR/CRP U&Es: dehydration, electrolye imbalance Glucose TFT LFT Ca Folate and B12 VDRL Consider EEG if epilepsy is ddx

Answer 470

Maximise orientation: treat senosry impairment, clear signage, clocks and calendars, appropriate lighting Prevent causes of deleirum: polypharmacy, constipation and dehydration, infection (avoid unnecessary catheterisation), assess for hypoxia and maximise O2 sats Promote well-being: encourage mobilisation, good pain control, diet, sleep hygiene, social interaction.

Answer 471

Treat underlying cause(s) If person is distressed/risk to him-self and not responding to verbal de-escalation consider using pharamcology: low dose and ST antipsychotics: haloperidol and antipsychotics. Do not use antipschotics in individuals with PD or LBD

Answer 472

Confusion Assessment Method A: acute onset and fluctuating course B: inattention C: disorganised thinking D: altered level of consciousness

Answer 473

Increases risk of dementia Mortality Length of hospital stay Risk of new admission to LT care

Answer 474

Multiple cognitive deficits e.g. memory, orientation, lanuage, comprehension, reasoning, judgement + Resulting impairment in ADLs + Clear consciousness Behavioural proglems, depression and anxiety, psychotic symptoms, sleep problems

Answer 475

Low educational attainment Obesity Untreated systolic HTN Depression Mental, social and physical inactivity

Answer 476

AD 55% Mixed AD and vascular 25% LBD 10% Frontotemporal dementia 5% Other 5%

Answer 477

Cortical or subcortical altough usually pathology involves both areas and the clinical features overlap

Answer 478

Cerebral cortex AD, LBD, frontotemporal Memory impairment, dysphasia, visuo-spatial impairment, problem-solving and reasoning deficits

Answer 479

BG, thalamus PD, HD, AIDs dementia, ETOH-related dementia Psychomotor slowing, impaired memory retrieval, depression, apathy, executive dysfuntion, personality change, language relatively preserved

Answer 480

Gradual onset usually with memory loss

Answer 481

Patchy cognitive impairment, focal neurological symptoms that appear in a stepwise fashion rather than continuous deterioriation NB many people have a mixed picture

Answer 482

Stroke-\> 9x increased risk of dementia in the following year

Answer 483

HTN Hypercholesterolaemia DM Smoking

Answer 484

Fluctuating cognition and alertness, vivid visual hallucinations, spontaenous parkinsonism, sensitivity to neurlopetics and sleep disorder Associated with LB and neurites in the basal ganglia and the cerebral cortex

Answer 485

Where Parkinson's disease predates the dementia by more than a year

Answer 486

Younger mean age of onset, characterised by early personality changes and relative intellectual sparing.

Answer 487

May be idiopathic or due to SAH, head injury or meningitis Marked mental slowness, apathy, wide-based gait and urinay incontinence. Ventriculoatrial shunting leads to frequent complications and tends to benefit only patients with prominent neurological signs and mild dementia

Answer 488

Dementia is FTD

Answer 489

Exclude treatable cause, NB superimposed acute confusional state, depression sometimes precedes or complicates established dementia and has a poor SSRI response. Control vascular risk factors Structured group cognitive stimulation programme. Rx: AChE inhibitors for management of mild-moderate AD: donepezil, galantamine and rivastigmine Memantine: NMDAR antagonist indicated in those with moderate AD who have intolerance to AChE or in severe AD

Answer 490

Should not be prescribed antipsychotic drugs due to the possible increased risk of CVA

Answer 491

Severe depression in old age which may present with prominent forgetfulness and self-care

Answer 492

Unstructured 6-10 sessions Establishing rapport, facilitating emotional expression, reflection, reassurance Non-directive problem solving e.g. for adjustment disorders, stress, bereavement, mild depression or anxiety

Answer 493

Structure Explicit Time limited 6-12 sessions Cognitive: identify automatic negative thoughts and core beliefs, behavioral graded exposure, activity scheduling Behavioural therapy: ABC (antecedents, beaviour, consequences e.g. for depression, anxiety, eating disorders, personality disorders, psychotic disorders

Answer 494

Unstructured Often for years Freee association Transference (the redirection to a substitute, usually a therapist, of emotions that were originally felt in childhood (in a phase of analysis called transference neurosis) Counter-transference (Countertransference occurs when a therapist transfers emotions to a client. It is often a reaction to transference, a phenomenon in which a client redirects his or her feelings for others onto the therapist.) PD

Answer 495

1 year. BPD

Answer 496

To help individuals identify and challenge automatic thoughts and then to modfiy any abnormal underlying core beliefs.

Answer 497

Operant condition: support (reinforcement), witholding reinforcement (negative)

Answer 498

Patient consents (before every treatment) Patient lacks capacity and it does not conflict with advance decision It's an emergency and independant consultant has not yet assessed or agrees

Answer 499

Severe depressive illness Prolonged, severe episode of mania that hasn't responded to treatment Catatonia Moderate depression that has not responded to mltiple drug/psychological treatments

Answer 500

Patients would need subsequent treatment for depression to prevent relapse e.g. with psychological and pharmacological therapy

Answer 501

Raised ICP Recent stroke Recent MI Crescendo angina (No absolute contraindications

Answer 502

Patients have reported that it can cause cognitive impairment. Anaesthetic complications Dyshythmias due to vagal stimuation Post-ictal headache. Confusion Retrograde and anterograde amnesias Cognitive function should be assessed before, during and after course of treatment. If there is evidence of any significant cognitive impairment at any stage consider chaning from bilateral to unilateral electrode placement stimulus dose stopping treatment

Answer 503

Bilateral anterior capsulotomy or anterior cingulotomy are performed Severe treatment-resistant depression and OCD 40-60% success rates reported

Answer 504

1/4 Doubles tthe likelihood

Answer 505

Improving access to psychological therapies To increase the avaialbility of psychological therapies for depression and anxiety either through computer-aided CBT or are stepped up to CBT or other evidence based psychological treatments

Answer 506

Psychiatrists, community pschiatric nurses, social workers, OTs and psychologists

Answer 507

Care Programme Approach CPA meetings take place every 6 months to devise a care plan documenting those involved in patient's care, the treatment plan, early relapse indicators and a crisis plan should the patient's mental health deteriorate Each patient has a care coordinator who implements the plan, sees the pt monthly and monitors their metnal state

Answer 508

Residential care Supported housing Floating outreach Social services, voluntary and independent sector organisations.

Answer 509

Their ability to self-care and the nature of their illness

Answer 510

Support, Time and Recovery, help service users to access a range of daytime activities

Answer 511

Intensive home support People in MH crisis To prevent admissions and support early discharge

Answer 512

Assertive outreach teams provide treatment and support in the community People who are chronically unwell with a history of disengaging from mental health services To provide care in a difficult to reach treatment group

Answer 513

Early Intervention in psychosis provide inensive treatment for the first 2-3 years of illness with a focus on promoting return to employment and education Patients newly diagnosed with psychosis. Promoting recovery in early stage of psychotic illness where evidence suggests treatment may be most effective

Answer 514

Provide treatment and support for adults with especially complex mental health needs

Answer 515

To aid with diagnosis and management of dementia in people with memory problems To increase diagnosis of dementia (

Answer 516

Substance abuse

Answer 517

Important for assessing compulsory detention Distinguish between: Crime against property and violence against person Crimes occuring during periods of illness and those during remission Precursors to past violence and the risk of recurrence.

Answer 518

Understand information relevant tot he decision Retain, use and weight that information Communciate that decision

Answer 519

If capacity: advance decision, LPA and says how to decide if someone has capacity and For adults without capacity allows professionals to act in best interests consult family/friends about decisions appoint IMCA for important decisiosn Apply DoLs to anyone deprived of liberty

Answer 520

\>18y/o It would not conflict with LPA,Court of Protection or advanced decision Person lacks capacity to decide whether to be admitted Suffering from mental disorder Not detained under MHA Application is not to enable mental health treatment in a hospital (should be under MHA0 It is in person's best interests and necessary and proprotionate to prevent harm 2 assessors must agree R/V at least annually. Patient or representative may appeal

Answer 521

A patient is judged to have a mental health disorder sufficiently severe to need detention i hospital in the interests of hisher own health/safety or for the protection of others. For those detained under longer sections, appropriate medical treatment must be available to them People cannot be detained due to LD alone, must be associated with dangerous conduct

Answer 522

Appliation made by AMHP (social workers, nurse, psychologist, OT, NR) Application is made on the recommendation of two approved clinicans (Section 12 approved- can be doctors, doctors with previous knowledge of the patient can make the recommendation even if they are not section 12 approved) For section 3 the AMHP has to consult NR and if they disagree the responsible clinician takes legal action to displace the NR.

Answer 523

Treatment in community of patient previously detained under 3/37. 6 months

Answer 524

Urgent assessment from community with no time to arrange section 2 1 doctor (AC) 72 hours

Answer 525

Urgent detention of in-patient. (not A&E) 1 doctor 72 hours

Answer 526

Urgent detention of psychiatric inpatient in absence of doctor RMN 6 hours

Answer 527

Removal from home to place of safety. Police officer 72 hours

Answer 528

Removal from public place to place of safety Police office 72 hours

Answer 529

Must either be assesssed for section 2/3 or discharged to become an informal patient

Answer 530

A guardian (usually an AMHP) nominated by local authority is empowered to ensure that an individual resides at a pecific palce, attends specific places for treatments etc and allows specified people access to their residence

Answer 531

Section 17 requires that patients on compulsory sectiosn can only have leave subject to the RC's specific instrcution. Patients can be fully discharged from a section before its expirationb y the RC, a MHRT (to whom patients can appeal within 14d for Section 2 or at any time during the first 6 m of a section 3). By a Mental Health Act managers (community members who act as nonexecuitve directors of a hospital) if patient appeals to them. By NR if not overuled by RC.

Answer 532

Remands an accused person to hospital for a report 1 doctor Crown/magistrates court 28d

Answer 533

Remans accused person to hospital for treatment 2 doctors Crown court 28d

Answer 534

Orders hospital admission or guardainship of a person convicted of imprisonable offences (except murder) 2 doctors MC/Crown Court 6m

Answer 535

Sends convicted pesron to hospital to treatment prior to senetencing 2 doctors CC/MC 28 days

Answer 536

Applies restriction that patient on another hospital section may notbe given leave, transferred or discharged without the Home Secretary's consent 1 doctor Crown Court Duration of section

Answer 537

Transfers sentenced prisoner to hospital for treatment 2 doctors Home office 6 months

Answer 538

5(2), 135, 136, 4 No except in an emergency

Answer 539

May be given medication for first 3 months Section 58, may be given medication/ after 3 months only with patient consent or an independent second opinion approved doctor agrees treatment after interviewing patient and discussing treatment with RC and two other professionals involved in the patients treatment SOAD also required for ECT if given to patients without capacity ECT cannot be given to patients with capacity without consent

Answer 540

Psychosurgery/surgical hormone implants Needs both consent and SOAD

Answer 541

Life-saving treatment Exempt from 58 and 57

Answer 542

1 d 2 e 3 b 4 c 5 c 6 h

Answer 543

1 d 2 d 3 c 4 f 5 a 6 h

Answer 544

1 b 2 a 3 d 4 f 5 i 6 e

Answer 545

1 h 2 c 3 i 4 d 5 e 6 f 7 a (the patient believes that their persecutors are taking the form of other people so may be aggressive to a member of the public they believe to be their persecutor in disguise)

Answer 546

``` 1 c (see Chapter 36) 2 g ``` 3 d 4 j 5 f 6 a

Answer 547

1 d 2 e 3 e 4 h 5 g 6 f 7 c

Answer 548

1 g 2 g 3 h 4 d 5 a 6 c

Answer 549

1 a 2 g 3 j 4 e 5 b 6 h 7 c

Answer 550

1 g 2 d 3 e 4 b 5 f 6 i (see Chapter 11, aetiology section)

Answer 551

1 h 2 g 3 f 4 e 5 d 6 c

Answer 552

1 f 2 e 3 c 4 g +5 d 6 c

Answer 553

1 j 2 d 3 c 4 h 5 g 6 e

Answer 554

1 e 2 i 3 a 4 c 5 f 6 g 7 b

Answer 555

C; Clozapine is only used when two other antipsychotics have failed because of side-effects (page 76); depot is only used where specifically indicated (e.g. because of patient preference or very poor adherence; NICE recommends commencing new patients on an atypical antipsychotic.

Answer 556

A; Antidepressants are generally only recommended for moderate and severe depression

Answer 557

D; It is more common in women, with high rates postpartum but not during pregnancy, and in higher socio-economic groups.

Answer 558

10. B (page 75). 11. A (page 27).

Answer 559

12. C; Benzodiazepines are not recommended.

Answer 560

13. B; It is egodystonic (the thought is unwelcome and recognised as alien; it is not what he thinks).

Answer 561

16. A; They usually grow up to be heterosexual.

Answer 562

17. D (page 39).

Answer 563

19. D; Not the CAGE is a useful screening, not diagnostic, test.

Answer 564

20. D (see Chapter 19).

Answer 565

21. D (page 46).

Answer 566

22. D (see Chapter 40; the Mental Capacity Act applies to those aged 18 and over).

Answer 567

24. B; This cannot be true, because rates of schizophrenia in the Caribbean are similar to those in the UK among the indigenous populations

Answer 568

25. C; Treatment under the Mental Health Act may not be given in prison; transfer always requires court approval; prisoners with mental illness are at high risk of suicide

Answer 569

26. D; The risks of prescribing and not prescribing need to be carefully weighed; lithium is more likely to be teratogenic than sertraline.

Answer 570

27. D; Incident depression in older age is more likely to be associated with brain imaging abnormalities, less likely to be associated with a positive family history, and less likely to be treated compared with depression in a younger person.

Answer 571

28. B; They are more common than dissociative disorders; dissociative disorders generally involve the nervous system; in neither disorder are symptoms deliberately feigned; if so, factitious disorder would be the correct diagnosis.

Answer 572

29. A; The others are more common after CVA

Answer 573

31. A; Benzodiazepines can contribute to or cause confusion.

Answer 574

32. B (pages 72, 81); Note that antipsychotic use is associated with cognitive decline.

Answer 575

33. C; It is often used as a treatment for the others. It is important that substance misuse problems are under control before initiating psychodynamic psychotherapy, because exposing unconscious conflicts can increase stress in the short term and this could lead to increased substance misuse as an unhelpful coping strategy.

Answer 576

34. D; Most authorities recommend continuing for 2–5 years after a psychotic episode; they generally demonstrate some effect within a week; they are usually taken orally.

Answer 577

36. D (page 80); It is teratogenic so female patients should always be advised to consult their doctor if planning a pregnancy because usually they will be changed to safer medication;sometimes patient and doctor decide the risks of stopping (relapse with increased risk of self-harm, accidents and stress) outweigh those of continuing to take it when pregnant.

Answer 578

37. A (see also Chapter 33).

Answer 579

38. B; Psychosis ( common; mental illness is more common (25%); see Chapter 38.

Answer 580

40. D; If a patient is detained under the MHA they receive psychiatric treatment under it

Answer 581

Bio-psycho-scoial with considerations for predisposing, precipitating and perpetuating factors Include a risk management plan making use of all available statuatory and nonstatutory resoruces

Answer 582

Behavioural and psychological symptoms of dementia (BPSD) refer to the often distressing non-cognitive symptoms of dementia and include agitation and aggressive behaviour. he spectrum of BPSD includes: (Adapted from5) Aggression Agitation or restlessness; screaming Anxiety Depression Psychosis, delusions, hallucinations Repetitive vocalisation, cursing and swearing Sleep disturbance Shadowing (following the carer closely) Sundowning (behaviour worsens after 5pm) Wandering Non-specific behaviour disturbance e.g. hoarding

Answer 583

16, under 16s can be made by someone with Gillick competence or someone with parental responsibility Ends at 18. Under 18s can rarely refuse treatment as it is often not in their best interests (4th Gillick criteria). Under 18s refusal with parents can be overturned by courts Over 18s refusal is finalas long as they have competence Under 16s who are not Gillick competence may have their confidentiality breached. Confidentiality can be breached up to 18 if in child's best interests.

Answer 584

Refusal rather than demand of treatment * Have to be seen by the doctor * Informed, competent, voluntary * Can be oral * Can’t refuse nursing care, oral hydration/nutrition * Inapplicable if there’s a large change in circumstances e.g. pregnancy * Inapplicable if there’s been a large change in treatment given (e.g. AIDS) since decision was made. So it should be kept up to date * If there are doubts over validity/applicability , it can be overridden in an emergency Withdrawal may be oral * Have to be seen by the doctor * Informed, competent, voluntary * Can be oral * Can’t refuse nursing care, oral hydration/nutrition * Inapplicable if there’s a large change in circumstances e.g. pregnancy * Inapplicable if there’s been a large change in treatment given (e.g. AIDS) since decision was made. So it should be kept up to date * If there are doubts over validity/applicability , it can be overridden in an emergency Withdrawal may be oral

Answer 585

Negative views about the world -\> Negative views about the future -\> Negative views about oneself -\> cycle

Answer 586

De-escalation: call for help, reasssure, talk calmly, use simple language, non-hostile, don't invade personal space, remove weapons, separate from other patients Offer oral medication: antipsychotics, BZDs IM rapid tranquilisation: lorazepam, haloperidol + promethazine (to prevent dystonia) Seclusion Post-incident review

Answer 587

IM haloperidol (risk of ESPEs) BZDs (2nd line): NB can cause paradoxical increase in confusion

Answer 588

Hypothyroidism B12 Syphillis (argyll-robertson pupils, accomodate but don't react to light) Lyme disease Pellagra (niacin, nictonic acid, B3 deficiency): dermatitis+diarrhoea+dementia, sunlight hypersensitivity

Answer 589

19-24= mild

Answer 590

MMSE MoCA Addenbrookes Cogntiive Examination (/100) AMTS: /10,

Answer 591

Cognitive stimulation therapy: memory training Validation therapy: respecting the patient's reality Reminiscence therapy: allowing them to talk about the past Multisensory therapy: variety of stimuli in specialised room

Answer 592

Home adaptation: notes, dictaphone, ID, contact number, dosset boxes, change from gas to electric Keep mind stimulates Social services Involve therapy Plan for deterioration

Answer 593

Cerebral atrophy: hippocampal esp Amyloid plaques NFTs Cholinergic longs

Answer 594

Amnesia, Aphasia, Agnosia, Apraxia Wandering, personality changes, mood lability, apathy, poor insight, aggression

Answer 595

5-10y survival

Answer 596

Hachinski's ischaemic score, MRI

Answer 597

Used in the diagnosis of vascular dementia

Answer 598

Eosinophllic cytoplasmic inclusions, clumps of alpha synuclein

Answer 599

Frontal and temporal lobe atrophy Pick bodies made of Tau

Answer 600

Tap on table, ask them to rais finger, stop tapping and they still raise finger Fist, edge, pal, repeat Interpret a proverb Name words beginning with S What is the best paid job in Britain? Clock drawing

Answer 601

The pulvinar sign refers to bilateral FLAIR hyperintensities involving the pulvinar thalamic nuclei. It is classically described in variant Creutzfeldt-Jakob disease (vCJD). It is also described in other neurological conditions: Fabry disease (although the hyperintense signal is seen on T1WI) bilateral thalamic infarcts ADEM Tonsi biopsy

Answer 602

Alcohol Use Disorders Identification Test (10 question test by WHO)

Answer 603

Pre-contemplation Contemplation (acceptane) Preparation Action Maintenance Relapse: common part of learning process, not a sign of failure

Answer 604

Sensation like inescts crawling over the skin, seen in delerium tremens.

Answer 605

At Risk Mental State Mild psychotic symptoms Brief limited intermittent psychotic symptoms (BLIPs)-

Answer 606

Precipitating cause Intelligent Acute Normal premorbid personality High social class Female Late onset

Answer 607

Gradual onset Young Negative symptoms Fhx Low IQ Social withdrawal before Lack of obvious precipitant

Answer 608

Organic Acute and transient psychosis Depression/BPAD Schizoaffective disorder Persistent delusional disorder Schizotypal/Schizoid PD

Answer 609

Reactive mood, hypersomnia, hyperphagia, heavy limbs, rejection sensitivity MAOIs e.g. phenelzine

Answer 610

\* Review diagnosis o Consider co-morbid conditions \* Check compliance e.g. blood test \* Check for substance misuse \* Change dose \* Change or augment medication \* Review psycho-social management \* ECT

Answer 611

Ligth therapy CBT SSRis

Answer 612

\>13/30 indicates depression

Answer 613

o Past \* Trigger? \* Planned or impulsive? \* Method? \* Final acts? \* Did you isolate yourself? \* Efforts to avoid discovery? \* Suicide note? \* Who called the ambulance? \* Did you believe it would kill you? o Present \* How do you feel about trying to harm yourself? \* Do you regret trying to kill yourself? \* Do you regret failing to kill yourself? \* Has anything changed since the attempt? o Future \* How do you see the future? \* Do you have any plans to harm or kill yourself? \* Do you think you might kill yourself? \* Can you think of anything that might stop you?

Answer 614

GAD7 score (/21)

Answer 615

Hyperventilation Palpitations Dizziness/faints Tingling lips Tinnitus Sweating Depersonalisation/derealisation Sense of doom

Answer 616

\* Openness o Curious vs cautious \* Conscientiousness o Organised vs impulsive \* Extraversion o Extrovert vs introvert \* Agreeableness o Friendly vs detached \* Neuroticism o Insecure vs secure

Answer 617

Complex visual pseudohallucinations due to visual impairment

Answer 618

Conner's questionnaire

Answer 619

Inhibited/reactive: fail to respond to social interactions Disinhibited: overly friendly to strangers, danger of abuse, socially inappropriate behaviour

Answer 620

\* Extreme fatigue, aches and pains \* \>6 months \* Usually follows viral infection \* Management o Set realistic exercise goals o CBT

Answer 621

Lower dose Switch from depot Switch to different Procyclidine: worsens anti-cholinergic side effects + tardive dyskinesia

Answer 622

Worsens Mx of TD- lower dose

Answer 623

Mesolimbic: emotion- antipsychotics reduce positive symptoms Mesocortical: cognition- antipsychotics reduce negative symptoms Tubulo-infundibular- endocrine: antipsychotics cause hyperprolactinaemia due to reduced dopamine inhibition of prolactin Nigrostriatal- movement: antipsychotics cause EPSEs

Answer 624

Rx PPI Avoid SSRIs, mirtazapaine instead Avoid due to risk of serotonin syndrome

Answer 625

N+V Gastric ulcers Anxiety Insomnia Increased suicidal ideation Sexual dysfunction Hyponatraemia (SIADH in elderly) Anticholinergic Loss of appetite Platelet dysfunciton: increased bleeding

Answer 626

Stop SSRIs 5HT antag: cyproheptadine IV fluids BZDs Cooling blankets

Answer 627

5HT agonist, indicated for ST treatment of anxiety disordesr Compared to BZDs: doesn't cause tolerance or dependence, less powerful, slower acting Side effects include headaches, dizziness, drowsiness

Answer 628

Reduces hypo symptoms

Answer 629

Because dopamine antagonists reduce dopamine inhibition of ACh

Answer 630

Mood congruent: BPAD Mood incongruent: schizophrenia Systematised: delusions which revolve around a cental theme e.g. government Unsystematised: delusions which are disconnected/unrelated. Primary/autochthonous: sudden, out of the blue with no obvious cause Secondary: understandable in context of patients mood

Answer 631

Functional: normal stimulus that activates same sensory modality e.g. voice when tap is running Reflex: stimulus in one sense triggers hallucination in another e.g. face when tap is heard Extracampine: outside the normal range of sensory perception e.g. hearing voices 2 miles away

Answer 632

2nd person: talking to patient 3rd person: talking about patient to each other Though echo Command hallucinations Running commentary

Answer 633

Formal thoguht disorder

Answer 634

Long sidetrack leading back to original point

Answer 635

Patient goes of on tangent failing to return to original point

Answer 636

Thinking moving rapidly between loosely related topics manifested by pressure of speech i.e. BPAD

Answer 637

Changing topic randomly with every sentence Schizophrenia

Answer 638

Patient's thought stop mid-sentence Schizophrenia

Answer 639

Patient repeats back what is said to them Schizophrenia

Answer 640

Repeating same word or gesture and being unable to stop@ organic brain disease Palilalia= whole word Logoclonia= last syllable

Answer 641

Random words forming meaningless sentences Schizo/BPAD

Answer 642

Vague phrases used instead of words e.g. whatsits Schizophrenia, dementia

Answer 643

Words used are related by sound rather than meaning BPAD

Answer 644

Inability to describe mood ASD, eating disorders, depression (esp somatisation)

Answer 645

Pragmatic, goal based, thought diary Collaborative effort Challenges NATs

Answer 646

Black and white thinking

Answer 647

Deeming failures to be caused by self

Answer 648

Making generalisations based on past experiences

Answer 649

Calling oneself names

Answer 650

Dwelling on insignificant detail

Answer 651

Dwelling on bad, ignoring good

Answer 652

Graded exposure Response prevention Relaxation techniques Thought stopping- interrupting thought e.g. elastic band Flooding Aversion therapy

Answer 653

Acceptance Address coping mechanisms- replace maladaptive behaviours with more appropriate ones Individual and group therapy BPD

Answer 654

CAMHS Schizo Eating disorders BPAD Substance misuse

Answer 655

Particular syndrome of parietal lobe injury: Left-right disorientation Dyscalculia Finger agnosia Agraphia

Answer 656

Cortically blind but continues to confirm ademantly that they can see

Answer 657

the wall or floor of the third ventricle