Psychiatry

Question 1

Conditions that can result from thiamine deficiency

Answer 1

Wernicke’s encephalopathy

Korsakoff Syndrome

Question 2

Symptoms of Wernicke’s encephalopathy

Answer 2

Classic triad of symptoms (note not everyone will have all three)

Acute confusion
Ocular-motor signs e.g. ophthalmoplegia, nystagmus
Ataxic gait

Other associated symptoms:

Peripheral neuropathy
Resting tachycardia
Signs of nutritional deficiency

Question 3

Treatment of Wernicke’s encephalopathy

Answer 3

Prophylaxis for ALL patients at risk:

IV Pabrinex BD infusion over 30 minutes for 3-7 days
Replace magnesium
DO NOT rehydrate with glucose as it exacerbates thiamine deficiency
Treat alcohol withdrawal if necessary

Can progress to Korsakoff syndrome

Question 4

Symptoms of Korsakoff syndrome

Answer 4

Significant anterograde amnesia
Retrograde amnesia can be present but less pronounced
Confabulation
Apathy

Question 5

Causes of Korsakoff syndrome

Answer 5

Thiamine deficiency
Untreated Wernicke’s encephalopathy
Head injury
CO poisoning

Question 6

Physical health screening in alcohol use disorder

Answer 6

Check for stigmata of liver disease

Check for cerebellar signs (ataxia, tremor, nystagmus etc.)

Raised MCV which stays raised for up to 6 months post abstinence

Raised GGT which is the most sensitive LFT for alcohol related liver inflammation

Liver US if needed

Question 7

Screening tests for substance abuse

Answer 7

Fast Alcoholic Screening Test
CAGE (alcohol)
CAGE-AID (alcohol and drugs)

Question 8

Principles of motivational interviewing

Answer 8

Develop discrepancy (develop goals)
Express empathy
Support self-efficacy
Roll with resistance

Question 9

Medications to prevent alcohol consumption

Answer 9

Disulfiram - irreversible inhibition of ALDH so alcohol cannot be converted leading to build up of acetaldehyde and symptoms such as nausea, vomiting, tachycardia, headache, flushing etc.

Acamprosate - reduces alcohol cravings by enhancing GABA transmission

Question 10

Opiate replacement therapies

Answer 10

Methadone - long acting synthetic opioid

Buprenorphine - partial opiate agonist

Question 11

Medication for opiate withdrawal

Answer 11

Lofexidine

Question 12

MRI findings in heavy drinkers

Answer 12

Cortical and subcortical atrophy

Prominent white matter loss

Question 13

Investigation in opioid use disorder

Answer 13

Urine drug screen
Gas chromatography mass spectrometry if urine screen is positive
Rapid plasma reagent if IV use suspected
HIV, Hepatitis and TB serology
Cultures to check for infection

Question 14

Cannabis MOA

Answer 14

THC binds to cannabinoid CB1 receptors in brain

Question 15

Heroin MOA

Answer 15

Crosses BBB and is powerful mu opioid receptor agonist
Inhibits release of GABA thus reducing the inhibitory effect of GABA on dopamine
Leads to increase in dopamine

Question 16

Topics to cover when assessing alcohol misuse

Answer 16

Lifetime pattern of consumption - e.g. age of first drink, age of regular drinking, periods of abstinence

Current consumption - e.g. how many days a week, how much per day

Signs of dependence - e.g. withdrawal, tolerance

Social and occupational issues due to alcohol

Previous attempts to stop

Physical and mental health

Question 17

Six stages of change

Answer 17

Pre-contemplation
Contemplation
Preparation
Action
Maintenance
Relapse

Question 18

Prodrome

Answer 18

Subtle signs such as social withdrawal, behavioural changes and functional impairment which can foreshadow schizophrenia

Question 19

Negative Symptoms

Answer 19

Affective flattening

Alogia (poverty of speech)

Avolition (lack of motivation)

Anhedonia

Anergia (lack of energy)

Apathy

Social withdrawal

Catatonia

Question 20

First rank symptoms of schizophrenia

Answer 20

Auditory hallucinations – especially 3rd person (people talking about you) or running commentary types

Thought abnormalities – insertion, broadcast, block, echo

Delusional perceptions

Somatic passivity – feeling that you are not in control of your thoughts and actions and/or are being influenced by another source

Question 21

Diagnostic criteria for schizophrenia

Answer 21

At least one of the following for a month:

Thought symptoms – insertion, echo, withdrawal or broadcast

Delusional symptoms – delusions of control, passivity or perception

Hallucinations – running commentary, discussing patient, talking to patient

OR least two of the below for a month:

Persistent hallucinations of any modality

Broken train of thought leading to incoherent or irrelevant speech

Catatonic behaviour

Negative symptoms such as marked apathy, blunting or withdrawal

Significant and persistent change in behaviour