Psychiatry Flashcards
1
Q
What are the three classes of personality disorder?
A
A - odd (paranoid, schizoid)
B - dramatic (histrionic, emotionally unstable, dissocial)
C - anankastic, dependent, anxious
2
Q
List which antidepressants are associated with the following risks: • Drug Interaction • Discontinuation Symptoms • Death from Overdose • Overdose • Stopping treatment due to side-effects • Blood Pressure Monitoring Needed • Worsening Hypertension • Postural Hypotension and Arrhythmia
A
- Drug Interaction: fluoxetine, fluvoxamine, paroxetine
- Discontinuation Symptoms: paroxetine
- Death from Overdose: venlafaxine
- Overdose: TCAs (except lofepramine)
- Stopping treatment due to side-effects: venlafaxine, duloxetine, TCAs
- Blood Pressure Monitoring Needed: venlafaxine
- Worsening Hypertension: venlafaxine, duloxetine
- Postural Hypotension and Arrhythmia: TCA
3
Q
How often should a patient with newly diagnosed depression be followed-up after starting an antidepressant?
A
Review after 2 weeks (if no particular risk of suicide), then every 2-4 weeks thereafter for 3 months
4
Q
Which low-intensity psychotherapies may be offered to patient with mild-to-moderate depression?
A
Individual-guided self-help based on the principles of CBT
Computerised CBT
Structured group physical activity programme
5
Q
Who should be offered group CBT?
A
Individuals with mild-to-moderate depression who decline low intensity psychological therapies
6
Q
Which high-intensity psychological therapies may be offered to patients with moderate-to-severe depression?
A
Individual CBT
Interpersonal Therapy
7
Q
Transitions between which antidepressants must you be particularly careful with?
A
From fluoxetine to other antidepressants (as fluoxetine has a long half-life)
From fluoxetine or paroxetine to a TCA (both drugs inhibit TCA metabolism so a lower starting dose may be needed)
To a new serotoninergic antidepressant or MAOI (because of risk of serotonin syndrome)
From non-reversible MAOI: a 2-week washout period is required (other antidepressants should not be prescribed during this period)
8
Q
Briefly outline the step by step pharmacological management for depression.
A
STEP 1: SSRI (e.g. sertraline)
STEP 2: Taper down SSRI, start SNRI (e.g. venlafaxine)
STEP 3: Add augmentation - either atypical antipsychotics (e.g. quetiapine) or another antidepressant (e.g. mirtazapine)
STEP 4: ECT
9
Q
Over what period of time should antidepressants be stopped?
A
4 weeks
10
Q
What needs to be monitored after a patient is started on lithium and how regularly should this happen?
A
Lithium levels - at 1 week after starting, then weekly until therapeutic level is reached. Then every 3 months (12 hours post dose).
U&E - every 3 months
TFTs - every 6 months
Creatinine clearance - annually
11
Q
Which mood stabiliser does not need monitoring of drug levels?
A
Sodium valproate
12
Q
How soon after an episode of self-harm should the patient be followed-up?
A
1 week
This can be in outpatient clinic, CMHT, GP or counsellor
13
Q
Which psychological therapies for patients who have self-harmed?
A
CBT
Mentalisation-based therapy
Transference-focused psychotherapy
14
Q
What are some coping strategies that can be used for patients with thoughts of self-harm?
A
Distraction techniques
Mood-raising activities (e.g. exercise)
Prevention of self-harm (put tablets and sharp objects away, stay in public places with supportive people, call a friend/support line, avoid drugs and alcohol)
15
Q
Which service should be involved in the care of a young person with first episode psychosis?
A
Early intervention service (EIS)
16
Q
Which receptors are blocked by typical and atypical antipsychotics?
A
Typical = dopamine (D2) Atypical = dopamine and 5HT2
17
Q
Which antipsychotics are particularly associated with weight gain?
A
Olanzapine and clozapine
18
Q
What is the main aim of CBT in schizophrenia?
A
Emphasis on reality testing
Encourage the patient to think about evidence and alternative explanations
19
Q
Which forms of psychological therapy may be useful in schizophrenia?
A
CBT (for all patients)
Family therapy (particularly useful if high expressed emotion)
Concordance therapy
20
Q
Which social aspects of a patient with schizophrenia require management?
A
Social skill training Education, training and employment Skills (e.g. cooking, budgeting) Housing Accessing social activities Developing personal skills (e.g. creative writing)
21
Q
What is treatment resistance schizophrenia?
A
Failure to respond to two or more antipsychotics, at least one of which is atypical, each given at a therapeutic dose for at least 6 weeks
22
Q
How is schizoaffective disorder treated?
A
Same treatment as schizophrenia
You may add a mood stabiliser or antidepressant for the affective component
23
Q
Which investigations are used in neuroleptic malignant syndrome?
A
CK (high)
WCC (high)
24
Q
How is neuroleptic malignant syndrome managed?
A
Stop antipsychotics immediately
Get urgent medical treatment (usually ITU)
Treat hyperthermia (cooling blankets, ice packs)
Dantrolene may be used for muscle rigidity
Benzodiazepines may be necessary for agitation
High myoglobin can cause AKI (IV fluids and dialysis may be required)
25
How should delirium tremens be managed?
```
Reducing benzodiazepine (chlordiazepoxide) regime
IV pabrinex
```
NOTE: lorazepam may be used in hepatic failure
26
What are the stages of change model?
```
Pre-contemplation
Contemplation
Preparation
Action
Maintenance
Relapse
```
27
Where can detoxification for alcohol be given?
Inpatient detox
| Community detox
28
What are some psychological therapy options for alcohol abuse?
CBT
Problem-solving therapies
Group therapy (alcoholics anonymous)
29
What are some medical management options for preventing relapse in alcohol abuse?
Acamprosate (anti-craving)
| Disulfiram
30
What do rehabilitation programmes for alcohol-abuse involve?
May be residential or day programmes
Allow a break for people submerged in a drinking community
May be skills-based courses to help find employment
31
What are some harm reduction approaches that are used for opiate misuse?
Needle exchange
| Vaccination and testing for blood-borne viruses for sex-workers and IVDU
32
Which agents may be used as substitutes in opiate misuse?
Methadone (liquid) or buprenorphine (sublingual tablet)
NOTE: these are taken in a supervised environment
33
Which medication can be used to prevent relapse in patients with opiate misuse?
Naltrexone
34
Outline the behavioural management approach for delirium.
Frequent reorientation (clocks, calendars)
Good lighting
Address sensory problems (e.g. hearing aids)
Minimise change (don't keep moving the patient, one staff member per shift, establish routine)
Allow safe and supervised wandering
35
Which agent is often used for rapid tranquillisation of an agitated patient?
Lorazepam
Alternative: olanzapine, haloperidol
36
How can normal pressure hydrocephalus be treated?
Ventriculoperitoneal shunt
37
What is a particularly important aspect of the management of depression in the elderly?
Problem-solving
| Increased socialisation and day-time activities
38
What are the main risks of using antipsychotics in the elderly?
Stroke and VTE
39
List some environmental adaptations that can be recommended for a patient with dementia.
Always carry ID, address and contact number in case they get lost
Dossett boxes/blister packs to aid medication compliance
Change gas to electricity
Reality orientation (visible clocks, calendars)
Environmental modifications (e.g. patterned carpets can predispose to hallucinations)
Assistive technology (e.g. door mat buzzers)
40
Which psychological therapies are available for patients with dementia?
Reminiscence therapy
Validation therapy
Multisensory therapy
Cognitive stimulation therapy (memory training)
41
What is the main pharmacological treatment option for patients with dementia?
Acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine)
42
Give an example of an anxiety disorder that is treated with exposure therapy.
Agoraphobia
43
What are the steps in the management of generalised anxiety disorder?
1) education about GAD + active monitoring
2) low-intensity psychological intervention (individual non-facilitated self-help or individual-guided self-help or psychoeducational groups)
3) high-intensity psychological intervention (CBT or applied relaxation) or drug treatment
4) highly specialist input
44
What is the first-line SSRI used for generalised anxiety disorder?
Sertraline
Paroxetine is the only licensed SSRI for GAD
45
What are the steps in the pharmacological management of generalised anxiety disorder?
1) SSRI
2) switch to SNRI
3) Add pregabalin
4) consider quetiapine (not licensed)
46
What are the management options for panic disorder?
CBT and SSRI
Offer TCA (e.g. clomipramine, imipramine) if SSRI is contraindicated or no response after 12 weeks
47
What are the main approaches to managing OCD?
CBT (exposure and response prevention)
SSRIs (most commonly fluoxetine)
2nd line: SNRI
3rd line: add atypical antipsychotic
48
What are two psychological therapies that are used to treat PTSD?
Trauma Focused CBT
| EMDR (eye movement desensitisation and reprocessing)
49
Which pharmacological treatments may be used in PTSD?
SSRIs (paroxetine and mirtazapine)
NOTE: mirtazapine is good if they are having problems getting to sleep
50
What are the aspects of management of medically unexplained symptoms?
```
Reattribution model
Avoid unnecessary investigations
Emotional support
Antidepressants
CBT
Graded exercise
```
51
What are some management options for chronic fatigue syndrome?
```
Graded exercise (scheduled and gradually increasing activity)
CBT
```
52
How are conversion disorders managed?
Encourage a return to normal activities and avoid reinforcing symptoms
Provide support for addressing stressors
53
What is the main difference between anorexia nervosa and bulimia nervosa?
Anorexia nervosa BMI < 17.5 or weight loss of > 15%
54
List some psychotherapy options that may be used for anorexia nervosa.
Eating Disorder CBT
Specialist Supportive Clinical Management (SSCM)
Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
Family Therapy (best for children)
Interpersonal Therapy
55
Which SSRI would be best to use in anorexia nervosa?
Fluoxetine (stable in terms of weight)
NOTE: you don't want to give these patients anything that will make them gain weight too rapidly
56
What is interpersonal therapy?
Examines how the patient interacts with other people and teaches social skills and improves social functioning
57
Which class of drugs may be beneficial in bulimia nervosa and why?
SSRIs (e.g. high-dose fluoxetine)
| Improves impulse control and reduces bingeing/purging behaviour
58
Which treatment option is best for children with eating disorders?
Family therapy (eating disorder-focused)
59
What are some treatment options for low libido?
Sensate Focus Therapy (ban intercourse, then progress to genital caressing and eventually intercourse)
Timetabling sex
60
List some physical/pharmacological treatments for erectile dysfunction.
Sildenafil
Intracavernosal prostaglandin self-injection
Vacuum pumps
61
How is postnatal depression managed?
Same as normal depression (CBT + SSRI)
62
Which SSRIs are recommended for postnatal depression?
Sertraline and paroxetine
63
If a patient with postnatal depression required admission, where should she be admitted?
Mother and Baby Unit
64
How is puerperal psychosis treated?
Antipsychotics
ECT may be required if severe
Admission to a mother and baby unit
65
How long does postnatal depression and puerperal psychosis usually take to recover?
Depression: 1 month
Psychosis: 6-12 weeks
66
Which mood stabiliser is considered safest to use in pregnancy?
Lamotrigine
Lithium --> Ebstein anomaly
Valproate and Carbamazepine --> NTD
67
What are the aspects of management of learning disabilities?
Treat physical comorbidity
Treat psychological comorbidity
Statement of Special Educational Needs (maximise potential)
Psychological therapy (group therapy, counselling)
68
Outline the aspects of managing autism spectrum disorder.
Support and advice for families (National Autistic Society)
Behaviour therapy
Speech and language therapy
Special education
Treat comorbid problems (e.g. epilepsy)
Antipsychotics and mood stabilisers are occasionally used
69
How is Asperger's syndrome managed?
Advice and support
| Social skills training
70
How is depression in children managed?
CBT
Antidepressants (fluoxetine) may be used in severe cases
71
How are anxiety disorders in children managed?
Psychological therapies (CBT)
72
Which investigations may be used for ADHD?
Questionnaires (Conner's Rating Scale)
Classroom observation
Educational psychological assessment
73
Which medications may be used for ADHD?
Methylphenidate, lisdexamphetamine
| Atomoxetine (non-stimulant)
74
What are some side-effects of drugs used in ADHD?
```
Insomnia
Reduced appetite (and growth)
```
75
What are the aspects of managing conduct disorder?
```
Family education
Family therapy (take a problem-solving approach)
Parent management training
Educational support
Anger management for children
```
76
What are the aspects of managing tic disorders?
```
Reassure and stress management
Habit reversal training
Exposure and response prevention
Clonidine (alpha-2 agonist)
Haloperidol (antipsychotic)
```
77
What are the treatment approaches for emotionally unstable personality disorder?
```
Dialectical behavioural therapy
Mentalisation-based therapy
Therapeutic communities
Arts therapy
Transference focused therapy
```
78
List some side-effects of SSRIs.
GI upset
GI bleeding (if using NSAIDs, give with a PPI)
Increased anxiety/agitation soon after starting
79
Which SSRIs have a high propensity for drug interactions?
Fluoxetine and paroxetine
80
Which SSRIs are associated with a dose-dependent increase in QTc?
Citalopram
| Escitalopram
81
Which drugs should not be used with SSRIs?
Warfarin
Triptans
MAOI
82
Outline the risks of SSRIs in pregnancy.
1st trimester: congenital heart defects
3rd trimester: persistent pulmonary hypertension
Paroxetine has an increased risk particularly in the 1st trimester
Sertraline, fluoxetine and citalopram are generally considered safe
83
How is acute dystonia treated?
Procyclidine
84
How is tardive dyskinesia treatad?
Tetrabenzene
85
What are the symptoms of neuroleptic malignant syndrome?
Pyrexia
| Muscle stiffness
86
Give some examples of TCAs that causes high sedation and low sedation.
High Sedation: amitriptyline, clomipramine, dosulepin, trazadone
Low Sedation: imipramine, lofepramine, nortriptyline
87
Which SSRI has a long half-life?
Fluoxetine
88
Describe how you should switch from citalopram, escitalopram, sertraline or paroxetine to another SSRI.
First should be withdrawn before the alternative is started
89
Describe how you should switch from fluoxetine to another SSRI.
Withdraw then leave a gap of 4-7 days (fluoxetine has a long half-life) before starting a low-dose of the new SSRI
90
Describe how you should switch from SSRI to a TCA.
Cross-taper
| Except with fluoxetine (withdraw completely before starting TCA)
91
Describe how you should switch from citalopram, escitalopram, sertraline or paroxetine to venlafaxine.
Cross-taper cautiously (starting on 37.5 mg OD venlafaxine and tapering upwards slowly)
92
Describe how you would switch from fluoxetine to venlfaxine.
Withdraw then start venlafaxine at 37.5 mg OD and increase very slowly
93
List some side-effects of clozapine.
* Agranulocytosis, neutropaenia
* Reduced seizure threshold
* Constipation
* Myocarditis (baseline ECG should be taken before starting treatment)
* Hypersalivation
94
List some side-effects of lithium.
o Nausea/vomiting and diarrhoea
o Fine tremor
o Nephrotoxicity: polyuria (secondary to nephrogenic DI)
o Thyroid enlargement (and hypothyroidism)
o ECG: T wave flattening/inversion
o Weight gain
o Idiopathic intracranial hypertension
95
How is the MMSE score interpreted?
24 or more = normal
18-23 = mild
10-17 = moderate
< 9 = severe
NOTE: raw score should be corrected based on educational attainment and age
96
What is the maximum score for a MoCA and what score would warrant further cognitive assessment?
Max = 30
| Refer for further assessment if 25 or less
97
What counts as mild, moderate and severe depression?
Mild
• 2 or 3 core symptoms
• At least 2 other symptoms
• The patient is distressed about the symptoms but can still continue with most activities
Moderate
• 2 or 3 core symptoms
• At least 3 or 4 other symptoms
• The patient has considerable difficulty continuing with ordinary activities and social functioning
Severe
• All 3 core symptoms
• At least 4 other symptoms, some of which are intense
• Major impact on quality of life and social functioning
• May show distress and/or agitation
NOTE: All symptoms must be present for at least 2 weeks
98
Outline how the PHQ-9 is interpreted.
```
9 questions each worth 3 points
None: 0-4
Mild: 5-9
Moderate: 10-14
Moderately Severe: 15-19
Severe: 20-27
```
99
Outline the interpretation of the HAD.
7 questions for anxiety and 7 for depression (maximum 21 points for each)
Normal: 0-7
Borderline: 8-10
Anxiety/Depression: 11-14
100
Outline how the GAD7 is interpreted.
```
Asks about 7 questions and their frequency
Mild: 5-10
Moderate: 10-15
Severe: 15+
Maximum = 21
```
NOTE: it can also be used for PTSD, panic disorder and social anxiety
101
List some screening tools used for alcohol misuse.
CAGE
| Alcohol Use Disorders Identification Test (AUDIT)
102
Name a tool used to assess the severity of alcohol withdrawal.
Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)
103
List some indications for ECT.
Catatonia
Prolonged or severe manic episode
Severe depression that is life-threatening
104
What criteria must be fulfilled for a diagnosis of chronic insomnia?
Diagnosed if a person has trouble falling asleep or staying asleep at least 3 nights per week for 3 months
105
What required monitoring during clozapine treatment and how regularly?
```
FBC
o Weekly for 18 weeks
o Then every 2 weeks up to 1 year
o Then monthly
Lipids and Weight
o Baseline
o Every 3 months for 1 year
o Annually
Fasting BM
o Baseline
o 1 month
o Every 4-6 months
Prolactin
o Baseline
o 6 months
o Annually
U&E and LFT
o At the start of therapy
o Annual
Blood Pressure
o Baseline
o Frequently during dose titration
ECG
o Baseline
Cardiovascular Risk Assessment
o Annually
```
106
What should be done if a clozapine dose is missed for > 48 hours?
The dose should be carefully retitrated up (as if starting therapy from scratch)
107
What is applied relaxation therapy?
Used for anxiety disorders
Teaches patients how to spot the signs of tension, relax their muscles to relieve tension and apply these techniques to stressful situations
12-15 weekly sessions
108
What is mentalisation-based therapy?
Used for emotionally unstable personality disorder and self-harm
Teaches how to take a step back and assess their mental state and the mental state of others
109
List some symptoms of serotonin syndrome.
```
Fever
Agitation
Hyperreflexia
Tremor
Sweating
Dilated pupils
Diarrhoea
```
110
What are the components of an AMTS?
How old are you?
What is the time to the nearest hour?
Give an address and ask them to recall it at the end
What is the year?
What is the name of the hospital or place you are currently at?
Can you recognise two people (doctor and nurse)?
What is your date of birth (day and month)?
In which year did WW2 begin?
Name the current prime minister.
Count backwards from 20 to 1
111
According to DSM-V, how long do symptoms last in acute stress reactions?
At least 3 days
| Should disappear within 1 month
112
How long do symptoms of generalised anxiety disorder have to last in order to be diagnostic?
6 months
113
How long do symptoms of PTSD have to last to be diagnostic?
> 1 month
114
What are the criteria for diagnosing ADHD?
Age 6-12 years
Occurring in > 1 environment
Clear evidence of academic or social problems
Duration of at least 6 months
115
By what age does autism start to impair function/manifest as abnormal development?
3 years
116
When does postnatal depression occur?
From anytime during pregnancy to within 1 year of delivery
117
What are the criteria for diagnosis of bipolar I disorder?
At least one manic episode
| Depressive episodes are common but not necessary to make the diagnosis
118
What are the criteria for diagnosis of bipolar II disorder?
At least one hypomanic episode (lasting at least 4 days)
| At least one major depressive episode
119
How long do features of conduct disorder need to occur to be diagnostic?
6 months
120
How long do symptoms of depression need to be present to be diagnostic?
2 weeks
121
Outline the classification of learning disability based on IQ.
o 50-70 = Mild
o 35-49 = Moderate
o 20-34 = Severe
o < 20 = Profound
122
Which features distinguish personality disorders from personality traits?
Pervasive: occurs in all/most areas of life
Persistent: evident in adolescence and continues through adulthood
Pathological: causes distress to self or others, impairs function
123
What are the two main subtypes of emotionally unstable personality disorder?
Impulsive: characterised predominantly by emotional instability and lack of impulse control
Borderline: characterised by disturbances in self-image, aims and internal preferences. Chronic feelings of emptiness, unstable interpersonal relationships and a tendency to self-destructive behaviour (including suicide gestures and attempts).
124
According to DSM-V, how long do psychotic symptoms need to be present to diagnose schizophrenia?
At least two diagnostic criteria present over much of the time for > 1 month
Significant impact on social and occupational functioning for > 6 months
NOTE: disorder lasting 1-6 months is schizophreniform disorder
125
According to DSM-V, how long do psychotic symptoms in schizoaffective disorder need to last to be diagnostic?
Psychosis must be sustained for > 2 weeks without affective symptoms
Requires 2 episodes of psychosis to qualify: 1 without affective symptoms, 1 with affective symptoms
126
What are the defining features of dependence syndrome?
Craving
Control (difficulties controlling use)
Persistent Use (despite knowledge of harmful consequences)
Priority (higher priority given to drug use than other normal activities)
Tolerance (increased)
Withdrawal
127
Define somatisation disorder.
• The main features are multiple, recurrent and frequently changing physical symptoms of at least 2 YEARS duration.
NOTE: if it has been going on for < 2 years, it is an undifferentiated somatoform disorder
128
How long should SSRIs be used for in a patient with depression?
Until 6 months after the patient's depression has ended
This can be extended to 1 year for elderly patients
129
What advice should you provide to a patient who is being started on SSRIs?
* Can cause hyponatraemia
* Can cause reduced libido/sexual dysfunction
* Lower seizure threshold (careful in epilepsy)
* Avoid in mania or hypomania
* Do not drink alcohol (increased sedation)
* Never drive if feeling drowsy on antidepressants
* Explain that the onset of action is delayed
130
List the side-effects of SNRIs.
Constipation
Hypertension
Raised cholesterol
They also have all the SSRI side-effects
131
List some side-effects of TCAs.
```
Tachycardia, arrhythmias
Dry mouth
Blurred vision
Constipation
Urinary retention
Postural hypotension
Sedation
Nausea
Weight gain
```
132
List some discontinuation symptoms of SSRIs.
Flu-like symptoms
Electric shock sensations
Headaches
Vertigo
133
What is considered treatment resistance depression?
Failure to respond to 2 adequate trials of different classes of antidepressants at adequate doses and for a period of 6-8 weeks
134
Which drugs can be used for augmentation if SSRI/SNRI was ineffective?
Atypical antipsychotic (e.g. quetiapine)
Lithium
Thyroxine
Buspirone
135
How long do low-intensity psychosocial interventions go on for?
Roughly 9-12 weeks with follow-up
136
How long do high-intensity psychological interventions go on for?
16-20 sessions over 3-4 months
137
Which services should be used to manage mental health crises?
Crisis resolution
| Home treatment team
138
Which antidepressant is recommended in patients with comorbid medical conditions due to low risk of drug interactions?
Sertraline
139
Which investigations should be considered in a patient presenting with depression?
```
o Collateral history
o Physical examination
o Bloods: FBC, TFT, U&E
o Rating Scale: PHQ9, HAD, CDI (children)
o Risk Assessment
```
140
Which investigations should be considered in a patient presenting with mania/BPAD?
o Collateral history
o Physical examination (establish baseline state)
o Bloods: FBC, TSH, U&E, LFT, ECG
o Urine drug screen
o Rating scale: Young Mania Rating Scale
o Risk assessment
141
What is the Young Mania Rating Scale?
Uses 11 questions with a total score of 60
| Scores
142
What is the therapeutic range for lithium?
0.6-1.0 mmol/L
Becomes toxic > 1.2 mmol/L
143
List some features of lithium toxicity.
* GI disturbance
* Sluggishness
* Giddiness
* Ataxia
* Gross tremor
* Fits
* Renal failure
144
Outline the management of lithium toxicity.
Stop lithium
Transfer for medical care (rehydration, osmotic diuresis)
If overdose is severe, the patient may need gastric lavage or dialysis
145
List some triggers for lithium toxicity.
Salt balance changes (e.g. dehydration, D&V)
Drugs interfering with lithium excretion (e.g. diuretics)
Accidental or deliberate overdose
146
How should depression in BPAD be managed?
Antidepressant + mood stabiliser OR antipsychotic
Risk of precipitating mania
147
How does the pattern of BPAD change with age?
Remissions become shorter and depressive episodes become more frequent
148
What is the antidepressant of choice to treat the depressive phase of BPAD?
Fluoxetine
149
List some features that suggest the patient is at high risk of attempting suicide again.
Careful planning
Final acts in anticipation of death (e.g. writing wills)
Isolation at the time of the act
Precautions taken to prevent discovery (e.g. locking doors)
Writing a suicide note
Definite intent to die
Believing the method to be lethal (even if it wasn't)
Violent method (e.g. shooting, hanging, jumping in front of a train)
Ongoing wish to die/regret that the attempt failed
150
What is the a community treatment order (CTO)?
Allows being discharged from a previous section but on the agreement that certain conditions are met such as:
Living in a certain place
Going somewhere for medical treatment
151
What is an IMHA?
Independent Mental Health Advocate
Advocate who helps the patient find out their rights under the MHA and provide support whilst detained
NOTE: patients on section 4, 5, 135 and 136 cannot have an IMHA
152
What are the main components of mental capacity?
Understanding information
Retaining information
Weighing up the options
Communicating their thoughts
153
```
State the duration of the following types of section.
2
3
4
5(2)
5(4)
35
37
135
136
```
```
2 - 28 days
3 - 6 months
4 - 72 hours
5(2) - 72 hours
5(4) - 6 hours
35 - 28 days
37 - 6 months
135 - 24 hours (up to 36)
136 - 24 hours (up to 36)
```
154
Who can make a section 2?
Made by an AMHP or nearest relative (NR) on behalf of TWO doctors, one or whom should be section 12 approved (usually SpR or consultant) and one of whom should know the patient in professional capacity (e.g. GP)
155
List some complications of bulimia nervosa.
```
Hypokalaemia
Dehydration
Enlargement of parotid glands
Dental caries
Mallory-Weiss tears
Osteoporosis
Russell's sign
```
156
Why should antipsychotics be avoided in Lewy Body dementia?
They precipitate parkinsonism
157
Under what conditions can activated charcoal be used for drug overdoses?
Oral drugs
| Within 1 hour of consumption
158
Which class of antihypertensive drugs are associated with causing a low mood?
Beta-blockers
159
What is the risk of a patient presenting with mania developing a depressive episode in the future?
>90%
160
How should benzodiazepines be withdrawn?
Reduce by 1/8 of the dose every fortnight
161
Which benzodiazepine has the shortest half-life and what are the clinical implications?
Lorazepam - leads to worse withdrawal symptoms
| Patients withdrawing may be switched from lorazepam to diazepam
162
What is the optimum dose of venlfaxine recommended for GAD?
75 mg
163
Which medication is most commonly used for the treatment of OCD?
Fluoxetine 60 mg (high dose)
164
What are the risks of using benzodiazepines in pregnancy?
1st trimester exposure is associated with cleft palette
165
What is the most common cause of maternal death during pregnancy and the 1st year postpartum?
Suicide
NOTE: within 6 weeks postpartum it is VTE
166
What is the mechanism of action of memantine?
NMDA receptor agonist
167
What guides the prescription of acetylcholinesterases for patients with Alzheimer's dementia?
MMSA 10-20
168
What proportion of patients diagnosed with anorexia nervosa will make a full recovery?
20%
169
List some clinical signs of anorexia nervosa.
Constipation
Bradycardia
Hypothermia
Sensitivity to the cold
170
List some biochemical consequences of bulimia nervosa.
Hypokalaemia
Hypocalcaemia
Hypotension
Reduced red cell count
171
What is the first line antipsychotic medication used for the treatment of a psychotic illness?
Olanzapine (usually starting with 10 mg)
Maximum dose: 20 mg (minimum therapeutic dose is 7.5-1 mg)
172
When is section 48 used?
For the transfer of an unsentenced prisoner to hospital for detention
Section 49 is a restriction order that can be applied by the Ministry of Justice
173
Which assessment tool is used to assess the risk of violence?
HCR-20
174
What is HoNOS?
Used to measure behaviour impairment, symptoms and social functioning
Used in severe mental illness
NOTE: GAS (global assessment scale) is a similar sale that assesses overall functioning in people with mental health problems
175
Which assessment tool is used to assess for the presence of psycopathy in patients?
PCL-R
176
What is overshadowing?
When a patient's presenting symptoms are assumed to be due to an underlying learning disability rather than another, potentially treatable, cause
177
What criteria need to be fulfilled to be able to discharge a patient with puerperal psychosis?
Developed some insight into the nature of the illness and is adherent with medication
No longer a risk to herself or the baby
178
Which investigations/further management should a GP recommend for a patient with suspected Alzheimer's disease?
Physical examination
Blood tests
Refer to old age psychiatry outpatient clinic (memory clinic)
179
If a patient has a mild cognitive impairment, who is responsible for informing the DVLA about the diagnosis?
If mild, the patient should be encouraged to inform the DVLA
If the patient continues to drive despite advice to inform the DVLA, the doctor can breach confidentiality
180
Which pre-existing conditions can be worsened by acetylcholinesterase inhibitors?
Peptic ulcer disease
COPD
Asthma
Cardiac arrhythmias
181
Which medications can be used for the treatment of acute mania?
Atypical antipsychotic
Lithium
Valproate
182
Define 1 unit of alcohol.
8 g of pure ethanol
10 ml of pure ethanol
Amount of alcohol that an adult can metabolise in 1 hour
183
What are the features of alcohol withdrawal syndrome and how long after the last drink will it occur?
```
4-12 hours after the last drink
Coarse tremor
Sweating
Insomnia
Tachycardia
Nausea and vomiting
Psychomotor agitation
Generalised anxiety
```
184
Which medications can be used for alcohol detoxification?
Chlordiazepoxide
Diazepam
NOTE: lorazepam can be used in cases of liver failure
185
What is the FAST screening tool?
Consists of a subset of questions from AUDIT
| A score of 3 or more is FAST positive
186
Outline how a score from AUDIT is interpreted.
```
20+ = possible dependence
16-19 = high risk
8-15 = moderate risk
0-7 = low risk
```
Max = 40
187
What counts as a 'brief intervention' for alcohol dependence?
5-10 mins of information
| 2-3 sessions of motivational interviewing
188
Which medications can be used for acute alcohol withdrawal?
Chlordiazepoxide
Diazepam
NOTE: carbamazepine is an alternative
189
Name two forms of nicotine replacement therapy.
Varenicline
| Bupropion
190
Describe the clinical features of opiate withdrawal.
```
Appear 6-24 hours after the last dose
Lasts 5-7 days
Dilated pupils
Sweating
Tachycardia
Hypertension
Piloerection (hairs on end)
Watering eyes/nose
Yawning
Cool, clammy skin (cold turkey)
```
191
Which medication can be used for symptomatic relief during opiate withdrawal?
Lofexidine (alpha agonist)
192
What is a major side-effect of chlorpromazine?
Skin photosensitivity (requires sunscreen)
193
What is a carer's assessment?
A free assessment that can be done by social services that conducts an interview with the carer and helps improve their ability to care for the patient
194
List some symptoms of refeeding syndrome.
```
Weakness
Fatigue
Rhabdomyolysis
Leucocyte dysfunction
Respiratory failure
Cardiac failure
Hypotension
Arrhythmia
Seizure
Coma
This phenomenon usually occurs within four days of starting to feed again.
```
195
Describe the pathophysiology of refeeding syndrome.
In starvation the secretion of insulin is decreased in response to a reduced intake of carbohydrates
Instead fat and protein stores are catabolised to produce energy
This results in an intracellular loss of electrolytes, in particular phosphate
Malnourished patients' intracellular phosphate stores can be depleted despite normal serum phosphate concentrations
When they start to feed, a sudden shift from fat to carbohydrate metabolism occurs and secretion of insulin increases
This stimulates cellular uptake of phosphate, which can lead to profound hypophosphataemia
196
Describe the features of benzodiazepine withdrawal.
```
Nausea and vomiting
Autonomic hyperactivity
insomnia
Delirium
Seizures
```
197
Describe the features of benzodiazepine use.
```
Loss of coordination
Slurred speech
Decreased attention and memory
Disinhibition
Aggression
Hypotension
Respiratory depression
```
198
Describe the features of amphetamine intoxication.
```
Euphoria
Insomnia
Agitation
Hallucination
Hypertension
Tachycardia
```
199
Describe the features of amphetamine withdrawal.
Dysphoric mood
Fatigue
Agitation
200
What is the difference between Fregoli and Capgras syndromes?
Fregoli: delusion that a persecutor is able to change into many forms and disguise themselves to look like different people
Capgras: delusional belief that a close acquaintance has been replaced by an identical double
201
List some examples of MAO inhibitors.
Selegiline
Phenylzine
Moclobemide (reversible)
202
What are the clinical features of the cheese reaction?
Severe hypertension
Tachycardia
Pyrexia
Tyramine is found in red wine, cheese, Marmite, broad beans)
203
List some transcultural psychiatric disorders.
Amox - Malaysia - frenzied killing spree
Koro - Asian - fear of penis disappearing
Piblokto - Inuits - sudden-onset hysteria (screaming)
Dhat - Indian - semen lost in urine
Latah - North Africa/Far East - exaggerated startle, echolalia or obeying commands, amnesia
Susto - South America - severe depressive episode after a traumatic event (often accompanied by diarrhoea and tics)
Windigo - North America - body is possessed by spirit that craves human flesh
204
List some causes of delirium.
```
Infection (e.g. UTI)
Hypoxia
Electrolyte disturbance
Constipation
Drugs
CNS disease
```
205
What type of drug is zopiclone?
Cyclopyrrolone
206
What type of drug is mianserin?
Tetracyclic antidepressant
207
Which tools are used to distinguish dementia from delirium?
Long Confusion Assessment Method (CAM)
| Observational Scale of Level of Arousal (OSLA)
208
Which low-intensity psychological therapies should be offered for GAD?
Individual non-facilitated self-help
Individual guided self-help
Psychoeducational groups
209
Which high-intensity psychological therapies should be offered for GAD?
CBT
| Applied relaxation
