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MRCP Part 1 > Psychiatry 1 > Flashcards

Psychiatry 1 Flashcards

1
Q

A 45yo man who takes Chlorpromazine for Schizophrenia presents with severe restlessness. What side effect of antipsychotic medication is this an example of?

A

Akathisia

Antipsychotics may cause akathisia (severe restlessness).

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2
Q

What is the mechanism of action of antipsychotics?

A

Antipsychotics act as Dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways.

Conventional antipsychotics are associated with EPSEs which has led to the development of atypical antipsychotics (such as Clozapine).

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3
Q

List 4 EPSEs. How might they be managed?

A
  • Parkinsonism
  • Acute dystonia: sustained muscle contraction (eg. 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.

EPSEs may be managed with Procyclidine.

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4
Q

The MHRA has issued specific warnings when antipsychotics are used in elderly patients. What are these?

A
  1. Increased risk of stroke

2. Increased risk of Venous thromboembolism.

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5
Q

List some side effects of antipsychotics.

A
  • Anti-muscarinic: dry mouth, blurred vision, urinary retention, constipation
  • Sedation, weight gain
  • Raised prolactin - may result in galactorrhea. Due to inhibition of the dopaminergic tuberoinfundibulnar pathway.
  • Impaired glucose tolerance
  • Neuroleptic Malignant syndrome: pyrexia, muscle stiffness
  • Reduced seizure threshold (greater with atypical)
  • Prolonged QT interval (particularly Haloperidol)
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6
Q

A 25 yo man with a history of schizophrenia is prescribed Olanzapine. Which one of the following adverse effects is he most likely to experience?

  • Anorexia
  • Parkinsonism
  • Hypertension
  • Weight gain
  • Agranulocytosis
A

Weight gain

  • The main advantage of the atypical agents is a significant reduction in extra-pyramidal side effects.
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7
Q

List 3 adverse effects of atypical antipsychotics.

A
  • Weight gain
  • Clozapine is associated with agranulocytosis
  • Hyperprolactinaemia
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8
Q

List some examples of Atypical Antipsychotics.

A
  • Clozapine
  • Olanzapine: higher risk of dyslipidaemia and obesity
  • Risperidone
  • Quetiapine
  • Amisulpiride
  • Aripiprazole: generally a good side-effect profile, particularly for prolactin elevation.
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9
Q

What is the main risk associated with Clozapine?
What monitoring is required?
When should Clozapine be used?

A

Risk: Agranulocytosis
Monitoring: FBC
Use: Clozapine should only be used in patients resistant to other antipsychotic medication.

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10
Q

What does the BNF state with regards to Clozapine?

A

‘Clozapine should be introduced if Schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each at least for 6-8 weeks

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11
Q

List 5 adverse effects of Clozapine.

A
  • Agranulocytosis, Neutropenia
  • Reduced seizure threshold (can induce seizures in up to 3% of patients)
  • Constipation
  • Myocarditis: baseline ECG should be taken before starting treatment
  • Hypersalivation
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12
Q

When might dose adjustment be required if a patient is taking Clozapine?

A

Dose adjustment may be necessary if smoking is started or stopped during treatment.

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13
Q

A 93yo female patient is experiencing visual hallucinations. She was admitted following a decline in mobility that was thought to be secondary to a UTI. She has improved clinically and biochemically and is awaiting a package of care before discharge.
She tells you earlier she saw small children running across the end of the bed and has done for many years. Her PMH includes hypertension, depression, age-related macular degeneration.
What should your management be?

A

Reassure the patient.

This most likely represents Charles Bonnet syndrome.

Reassurance is usually the best treatment, helping people to understand and come to terms with their hallucinations.

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14
Q

What is Charles Bonnet syndrome?

A

CBS is characterised by persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness.
This is generally on a background of visual impairment (although visual impairment is not mandatory for a diagnosis).
Insight is usually preserved.
This must occur in the absence of any other significant neuropsychiatric disturbance.

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15
Q

List 5 risk factors for Charles Bonnet syndrome.

A
  • Advanced age
  • Peripheral visual impairment
  • Social isolation
  • Sensory deprivation
  • Early cognitive impairment.
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16
Q

Which are the most common ophthalmological conditions associated with Charles Bonnet syndrome?

A
  • Age-related Macular degeneration
  • Glaucoma
  • Cataract
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17
Q

What is the prevalence of complex visual hallucinations in individuals with severe visual impairment?

A

Approx 10 - 30%

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18
Q

What is the prevalence of Charles Bonnet syndrome in visually impaired people?

A

Approx 11 - 15%

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19
Q

How long does Charles Bonnet syndrome tend to last?

A

In a study published by the British Journal of Ophthalmology, 88% of people had CBS for 2 years or more, resolving in only 25% at 9 years.
Thus, CBS is not generally a transient experience.

20
Q

A 16yo girl is brought for review by her father. She is a talented young violinist and is due to start music college in a few weeks time. Her parents are concerned she has had a stroke as she is reporting weakness on her right side. Neurological examination is inconsistent and you suspect a non-organic cause for her symptoms.
Despite reassurance about the normal examination findings, the girl remains unable to move her right arm.
What is the most appropriate term for this behaviour?

A

Conversion disorder: typically involves loss of motor or sensory function.

May be caused by stress.

  • This is a typical conversion disorder. There may be underlying tension regarding her musical career which may be manifesting itself as apparent limb weakness.
21
Q

What is ‘Somatisation Disorder’?

A
  • Multiple physical SYMPTOMS present for at least 2 years

- Patient refuses to accept reassurance or negative test results

22
Q

What is ‘Hypochodrial Disorder’?

A
  • Persistent belief in the presence of an underlying serious disease eg. cancer
  • Patient refuses to accept reassurance or negative test results.
23
Q

What is ‘Conversion Disorder’?

A
  • 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.
24
Q

What is ‘Dissociative Disorder’?

A
  • Dissociation is a process of ‘separating off’ certain memories from normal consciousness
  • Involves psychiatric symptoms eg. Amnesia, fugue, stupor
25
Q

What is ‘Factitious Disorder’?

A
  • Also known as Munchausen’s syndrome

- The intentional production of physical or psychological symptoms.

26
Q

What is ‘Malingering’?

A

Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain.

27
Q

A 62yo man is brought to the doctors by his daughter. Four weeks ago, his wife died from metastatic breast cancer. He reports being tearful everyday but his daughter is concerned because he is constantly ‘picking fights’ wither her over minor matters and issues relating to their family past.
The daughter also reports that he has, on occasion, described hearing his wife talking to him and on one occasion he prepared a meal for her.
Despite this, he has started going walking again and says he is ‘detemined to get back on track’.
What is the most likely diagnosis?

A

Normal Grief Reaction

28
Q

One of the most popular models of grief divides “grief’ in to 5 stages. What are these?

A
  1. Denial: This may include a feeling of numbness and also pseudo hallucinations of the deceased, both auditory and visual. Occasionally people may focus on physical objects that remind them of their loved one or even prepare meals for them.
  2. Anger: this is commonly directed against other family members and medical professionals
  3. Bargaining
  4. Depression
  5. Acceptance
  • Many patients will not go through all 5 stages.
29
Q

When might an abnormal or atypical grief reaction be more likely to happen?

A

Atypical grief reactions are more likely if:

  • Female sex
  • Sudden / unexpected death
  • Problematic relationship before death
  • Patient has not much social support
30
Q

Atypical grief reactions may include ‘delayed grief’ and ‘prolonged grief’. Define both of these.

A

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.

31
Q

A 36yo female is started on Haloperidol for treatment-resistant Schizophrenia. She presents with a 1-day history of neck pain and difficulty moving the neck.
On examination, she had normal observations except a mild tachycardia of 105 and neck stiffness with a restricted range of motion.
Her neck is involuntarily flexed to the right. She has normal facial movements.
What is the most likely diagnosis?

A

Torticollis

This patient has experienced acute dystonia secondary to commencing typical antipsychotic (Haloperidol).

Torticollis (‘wry’ neck) can be diagnosed where there is unilateral pain and deviation of the neck with pain on palpation and restricted range of motion.

32
Q

How is Neuroleptic Malignant Syndrome characterised?

A

Seen in patients taking antipsychotics:

  • Altered mental state
  • Generalised rigidity
  • Fever
  • Fluctuating blood pressure
  • High temperature
33
Q

Describe what you might see if a patient is having an Oculogyric crisis.

A

Oculogyric crisis is an example of an acute dystonia.

  • Upward deviation of the eyes
  • Clenched jaw
  • Hyperextension of the back / neck with torticollis
34
Q

What is ‘Tardive dyskinesia;?

A

Tardive dyskinesia occurs in patients on long term typical antipsychotics.
Characterised by uncontrolled facial movements, such as lip-smakin.

35
Q

What is Akathisia?

A
  • Characterised by severe restlessness with patients having difficulty in sitting still
  • Patients may rock, tap their legs or cross and uncross the legs.
  • Typically occurs with long term use of antipsychotics.
36
Q

A 33yo female is diagnosed with a personality disorder by her community psychiatrist. She has struggled to hold down a job as an Assistant Store Manager as she often finds her colleagues to be lacking in morals or values and is reluctant to delegate work to them.
She feels that her colleagues are lazy and do not perform their duties to a high standard. As a result, she is often overwhelmed with outstanding tasks that she cannot complete and ends up staying late to get things right.
What personality disorder is she most likely to have been diagnosed with?

A

Obsessive-Compulsive Personality Disorder:
Patients with obsessive-compulsive personality can be rigid with respect to morals, ethics and values and are often reluctant to surrender work to others.

37
Q

How does ‘Obsessive-Compulsive Personality Disorder’ differ from Obsessive-Compulsive disorder?

A

OCD: Patients typically become consumed with repetitive compulsions such as hand washing or checking lights.

Obsessive-Compulsive PERSONALITY disorder: - Often meticulous and rigid with respect to moral, ethics and values and can be unwilling to change their mindset on these.

  • Features of perfectionism. Only able to complete their work at the expense of social activities.
  • Struggle to delegate or trust others with their work
38
Q

Describe a patient with ‘Avoidant’ Personality Disorder.

A

Avoidant Personality Disorder:

  • Tend to avoid social contact / relationships due to fear of being criticised, rejected or embarrassed
  • View themselves as inferior to others - less keen to be involved unless they are certain of being liked.
39
Q

Describe a patient with ‘Dependent’ personality disorder.

A

Dependent Personality Disorder:

  • Struggle to make every day life decisions
  • Require reassurance and support from others
40
Q

Describe a patient with ‘Narcissistic Personality Disorder’.

A

Narcissistic Personality Disorder:

  • Heightened impression of self-importance and entitlement, often believing they have unlimited abilities to succeed, become powerful or look beautiful.
  • Patients lack empathy, and will happily take advantage of others to achieve their own need.
41
Q

Describe a patient with ‘Schizoid’ personality disorder.

A

Schizoid Personality Disorder:

  • Lack close friendship/companions
  • Are indifferent to praise making
  • Do not hold strong moral values
  • Lack perfectionist traits seen in other personality disorders.
42
Q

How would you manage someone with a personality disorder?

A
  • Personality disorders are thought to be ‘untreatable’ by definition
  • However, a number of approaches have been shown to help patients, including:
    > psychological therapies
    > Dialectical behaviour therapy
43
Q

Describe a patient with ‘Antisocial Personality Disorder’.

A
  • Failure to conform to social norms with respect to lawful behaviours: repeatedly performs acts that are grounds for arrest
  • Deception / conning others for personal profit or pleasure
  • Impulsiveness, Irritability and aggressiveness
  • Reckless disregard for safety of self or others
  • Lack of remorse
44
Q

Describe a patient with Borderline Personality disorder.

A
  • Efforts to avoid real or imagined abandonment
  • Unstable interpersonal relationships: alternate between idealisation and devaluation
  • Impulsivity in potentially self-damaging area
  • Recurrent suicidal behaviour.
45
Q

Describe a patient with Histrionic Personality Disorder.

A
  • Inappropriate sexual seductiveness
  • Need to be the centre of attention
  • Physical appearance used for attention seeking purposes
  • Relationships considered to be more intimate than they are.
46
Q

Describe a patient with ‘Paranoid’ personality disorder.

A
  • Hypersensitivity and an unforgiving attitude when insulted
  • Unwarranted tendency to question the loyalty of friends
  • Preoccupation with conspiratorial beliefs and hidden meaning
47
Q

Describe a patient with ‘Schizotypal’ personality disorder.

A
  • Ideas of reference (differ from delusions in that some insight is retained)
  • Odd beliefs and magical thinking
  • Unusual perceptual disturbances
  • Odd, eccentric behaviour
  • Lack of close friends other than family members
  • Inappropriate affect
  • Odd speech without being incoherent.

MRCP Part 1 (16 decks)

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