Psychiatry Flashcards
How can antipsychotic concordance and compliance be improved?
Depot medication
Define malingering
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
What is the first-line management for anorexia nervosa in young people and children?
Anorexia-focused family therapy
What are the symptoms of SSRI discontinuation syndrome?
Unsteadiness
Increased mood change
Electric shock sensations (Paraesthesia)
Anxiety
Difficulty sleeping
Restlessness
Gastrointestinal symptoms - pain, cramping, diarrhoea, vomiting
Prior to commencing electroconvulsive therapy, what are the recommendations for Antidepressant therapy?
Dose reduction
Define conversion disorder
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
What is the definitive management of acute dystonia?
Oral procyclidine
What are the presenting features of acute dystonia?
Sustained muscle contractions (torticollis, oculogyric crisis)
What risk is associated with SSRI use in the first trimester of pregnancy?
Congenital malformations
What risk is associated with the use of SSRIs in the third trimester of pregnancy?
Persistent pulmonary hypertension of the newborn.
What are the typical features of post-concussion syndrome?
Headache
Fatigue
Anxiety/depression
Dizziness
What is the difference between Knight’s move thinking versus Flight of ideas?
Differentiating between Knight’s move and flight of ideas - Knight’s move thinking there are illogical leaps from one idea to another, flight of ideas there are discernible links between ideas
What features differentiate depression from dementia?
Rapid onset
Biological symptoms and global memory loss
What side effect is associated with mirtazapine?
Increased appetite
What is the tyramine cheese reaction?
Monoamine oxidase inhibitor - consumption of food high in tyramine (cheese) –> result in a hypertensive crisis
What investigation should be performed prior to initiating clozapine?
Full blood count - risk of agranulocytosis
Which category of patients is predisposed to agranulocytosis on clozapine therapy?
Afrocarribean patients with benign ethnic neutropenia - manage with lithium and filgastrin
What is the management of tardive dyskinesia?
Prescribe tetrabenazine
How regularly should U&Es and TFTs be monitored on lithium therapy?
Every 6 months
What happens to clozapine levels if smoking cessation occurs abruptly?
Clozapine level increases - therefore necessitating dose adjustment.
What side effects are associated with TCAs?
antagonism of histamine receptors
drowsiness
antagonism of muscarinic receptors
dry mouth
blurred vision
constipation
urinary retention
antagonism of adrenergic receptors
postural hypotension
lengthening of QT interval
Nihilistic delusions concerning the belief of death or decay are described as what eponymous psychiatric phenomenon?
Cotard syndrome
What class of drug is venlafaxine?
serotonin and noradrenaline reuptake inhibitor
What risk factors are associated with bipolar affective disorder?
- Family history of bipolar disorder or suicide – 1st-degree relatives – 7x increased risk.
- Substance misuse disorders
- Pattern of psychosocial instability.
- Earlier age of onset (peak age 15-19 years) – abrupt onset
What is the definition of Type 1 bipolar affective disorder?
Mania and depression
What is the definition of type II bipolar affective disorder?
Hypomania and depression
What is rapid cyclic BPAD?
> 4 episodes/year (respond to sodium valproate)
What is the pharmacological management for rapid cyclic BPAD?
Sodium valproate
What are the three core features of a depressive episode?
Low mood
Anhedonia
loss of energy
What are the characteristic features of mania?
- Elevated mood, extreme irritability + aggression
- Increased energy or activity, restlessness, and a decreased need for sleep
- The pressure of speech or incomprehensible speech
- Flight of ideas or racing thoughts
- Poor judgement – risky activities – gambling.
- Distractibility, poor concentration
- Increased libido, disinhibition, and sexual indiscretions + sexual promiscuity
- Extravagant or impractical plans
- Increased sociability
- New religious ideas
- Psychotic symptoms: Grandiose delusions or hallucinations (usually voices)
How long should a manic episode last for diagnosis?
7 days
What psychotic symptoms are associated with mania?
Delusions of grandiosity + auditory hallucinations
What are Schneider’s 1st rank symptoms?
Thought interference
Delusional perception
Auditory hallucinations
What clinical features are consistent with the diagnosis of hypomania?
Mild elevation of mood or irritability
Increased energy and activity
Increased sociability, talkativeness, and over-familiarity
N.B: There is an absence of psychotic features + there is no impairment in social or occupational functioning
Minimum period - 4 days
How long should symptoms of hypomania last at least for diagnosis?
At least for 4 days
What rating scale is used to assess for BPAD in young children?
Young Mania Rating Scale
What is the first-line management in primary care for a patient with suspected Bipolar?
Refer to specialist care for mental health assessment
1. CAMHS for <14 years
2. Specialist early intervention service in psychosis for 14-18 years
What mood stabiliser is indicated in the management for bipolar affective disorder?
Lithium
When is lithium prescribed after an acute episode of Bipolar affective disorder?
4 weeks after the acute episode
What is the alternative to lithium as a mood stabiliser in bipolar?
Sodium valproate
What is the therapeutic range of lithium in BPAD?
0.6-1.0 mmol/L
At what level does lithium become toxic?
> 1.2 mmol/L
Prior to commencing lithium, what investigations are performed at baseline?
TFTs
U&Es
FBCs
After a dose adjustment of lithium, when should levels be measured?
12 hours since dose change
When should plasma lithium levels be checked after dose adjustment to assess for stability?
1 week - aim for 0.6-0.8 mmol/L
How frequently are plasma lithium levels assessed?
Every 3 months
How frequently are U&Es and TFTs measured for patients on lithium therapy?
Every 6 months
What congenital malformation is associated with lithium during pregnancy?
Ebstein’s anomaly
What is the management of mania in Bipolar Affective Disorder (Acute)?
Atypical antipsychotics - Olanzapine, quetiapine, risperidone
What is the second line therapy for the management of mania?
Switch to a different atypical antipsychotic
What is the third line therapy for the management of psychosis in mania if two atypical antipsychotics have been trialed?
Clozapine
What is the definitive management if mania is unresponsive to pharmacological management?
ECT
What is the second-line prophylaxis for bipolar?
Lamotrigine
Recommended management for anti-depressant therapy in diagnosed bipolar?
Discontinue antidepressant
What is the clinical presentation of lithium toxicity?
- GI disturbance
- Nausea and vomiting
- Polydipsia/polyuria
- Sluggishness
- Giddiness
- Ataxia
- Gross tremor
- Fits
- Renal failure
What are the long-term complications associated with lithium therapy?
- Renal failure
- Nephrogenic diabetes insipidus
- Hyperparathyroidism + hypercalcaemia
- Hypothyroidism – thyroid enlargement
- Leucocytosis
- Idiopathic intracranial hypertension
Which drugs can interfere and potentiate lithium toxicity?
- Diuretics interfere with lithium excretion.
What is the management for lithium toxicity?
Stop lithium dose and if severe, consider gastric lavage
What complication is associated with sodium valproate during pregnancy?
Spina bifida
What is the ICD-10 definition of acute stress reaction?
A transient disorder that develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress and that usually subsides within hours or days.
* Occurs within 3 days to 4 weeks of a traumatic event >1 month, consider PTSD.
What are the most common traumas associated with acute stress reaction?
Common Traumas:
1. Motor vehicle accident
2. Mild traumatic brain injury
3. Assault
4. Burn
5. Industrial accident
6. Witnessing a mass shooting
What are the clinical manifestations of acute stress reaction?
- Initial state of daze (may manifest as stupor)
- Constriction of consciousness field
- Narrowing of attention
- Inability to comprehend stimuli; disorientation.
Negative mood
Intrusion syndrome
Dissociative symptoms
Avoidance
Arousal
What arousal symptoms are associated with acute stress reaction?
- Sleep disturbance
- Irritable behaviour
- Hypervigilance
- Problems with concentrations
- Exaggerated startle response.
What intrusion symptoms are associated with acute stress reaction?
- Recurrent, involuntary, and intrusive distressing memories of the traumatic event.
o Children – Repetitive play. - Recurrent distressing dreams
- Dissociative reactions (flashbacks) – as if the traumatic events are recurring.
- Intense or prolonged psychological distress.
What are the autonomic signs of panic?
- Tachycardia
- Tachypnoea
- Sweating
- Hypertension
- Hyperactive
- Partial or complete amnesia may be present.
What is the first line management for acute stress reaction?
Trauma-focussed CBT - cognitive restructuring and exposure
CR - Address unrealistic appraisals the patient may have about trauma
Exposure - Confront their feared memories and situations - repeat confrontation of traumatic memories and safe reminders
What medication can be prescribed for short-term distress in a patient with acute stress reaction?
Benzodiazepine - manages sleep disturbance and agitation
What caution should be considered when prescribing benzodiazepines?
Addictive potential
Define adjustment disorder and prolonged grief reaction:
A state of subjective distress and emotional disturbance, interfering with social functioning and performance, arising in the period of adaptation to a significant life change or a stressful life event.
What are the three diagnostic criterions for adjustment disorder?
Adjustment disorder with depressed mood is characterised by the following diagnostic criteria:
1. Low mood, tearfulness, or feelings of hopelessness that occur in response to an identifiable stressor within 3 months of the onset of the stressor.
a. Does not last more than 6 months.
2. Significant distress that exceeds what would be expected given the nature of the stressor.
3. Impaired social or occupational functioning.
What is the duration of adjustment disorder?
Symptoms within 3 months of the onset of the stressor until 6 months.
What are common stressors result in adjustment disorder?
Divorce
Unemployment
Death
What is the presentation of adjustment disorder?
- Depressed mood
- Anxiety and worry
- The feeling of inability to cope.
- Disability in the performance of daily routine.
N.B: Without biological symptoms of depression (there is no impact on sleep, appetite, energy levels and no suicidal ideation).
What is the difference between depression and prolonged grief reaction?
- The sadness and symptoms are centred around the person who was lost, as opposed to the self; they are specific and not free-floating.
What is the period for prolonged grief reaction?
6 to 12 months
What is the first line management for adjustment disorder?
Supportive counselling
Antidepressants anxiolytics/hypnotics
What is the time period for PTSD?
> 1 Month
What are the four features associated with PTSD?
Intrusion symptoms
Avoidance symptoms
Negative condition and mood
Hyperarousal
What investigations are performed to screen for PTSD?
20-item self-report measure assessing 20 DSM-5 symptoms
OR
Trauma-screening questionnaire (TSQ)
What is the first line management for PTSD?
Trauma-focussed cognitive behavioural therapy within 1 month of a traumatic event
- Exposure therapy
What is the second line management for PTSD following trauma-focussed CBT?
Eye movement desensitisation and reprocessing (EMDR)
What are the indications for EMDR in PTSD Management?
> 3 months of symptoms related to non-combat trauma.
What drug is indicated in the management for PTSD?
SSRIs
How long should symptoms of GAD be for until diagnosis?
6 months
Define GAD
Generalised anxiety disorder (GAD) is characterised by excessive and persistent uncontrollable disproportionate worry that manifests as a significant impairment to social and occupational functioning for most days at least 6 months.
What are the risk factors associated with GAD?
Divorce, lone parent, living alone, 35-54 years old
What is the DSM-5 criteria for diagnosing GAD?
Worry must be greater than expected given the situation accompanied by 3 somatic symptoms:
o Restlessness
o Irritability
o Sleep disturbance
o Muscle tension
o Difficulty concentrating
o Fatigue
What are the somatic symptoms associated generalised anxiety disorder?
o Muscle tension or motor restlessness
o Sympathetic autonomic overactivity
Frequent gastrointestinal symptoms
Palpitations
Sweating
Trembling
Shaking
Dry mouth
- Subjective experience of nervousness
o Restlessness
o Irritability
o Sleep disturbance
What are the coping mechanisms for GAD?
Alcohol
Drugs
Avoidance
What questionnaire is used to screen for GAD?
GAD-7 questionnaire
What cut off score for severe GAD?
15
What cut off score for Moderate GAD?
10-14
What is the first line management for GAD?
- Communicate information (Information guide) + active monitoring + exercise.
What is the second step for GAD management?
Offer low-intensity psychological interventions:
* Individual non-facilitated self-help – Based on CBT – 6 weeks.
* Individual guided self-help – 6 weeks, weekly therapist appointment.
* Psychoeducational groups – 6 weeks <12/group.
What are low-intensity psychological interventions?
- Individual non-facilitated self-help
Guided self-help
Psychoeducational groups
What is step 3 for GAD management?
For patients with marked functional impairment or with GAD unresolved despite step 2 interventions provided.
Pregnant women with GAD
* High-intensity-intensity psychological interventions + Drug Treatment (SSRI)
o CBT – 12-15 weeks, 16-20 hours/day.
o Applied relaxation.
What is the first line management of GAD for patients with marked functional impairment?
High-intensity psychological intervention + SSRI
- CBT
-Applied relaxation
What is the difference in clinical presentation (pattern of memory loss) between pseudodementia and dementia?
Severe depression can mimic dementia but gives a pattern of global memory loss rather than short-term memory loss - this is called pseudodementia
Duration of social anxiety disorder for diagnosis?
6 months
Mean age of onset for social anxiety disorder?
13 years (more common in women than in men)
What are the risk factors associated with social anxiety disorder?
Anxiety
Mood and substance-use disorders
Positive family history
Define social anxiety disorder
A persistent and intense fear of being embarrassed, humiliated or negatively evaluated in social situations Leading to significant distress or impairment in functioning.
What are the clinical manifestations associated with social anxiety disorder?
The social fears are confined to performance situations,
* Shyness + Social skill deficits
- Ill at ease, minimal eye contact, offering. Brief answers to questions.
- Quiet tone of speech
- Difficulty initiating conversations
- Anxiety heightened
- Anticipatory – worrying for hours or days prior to a feared event.
- Avoidance behaviours
Self-scrutiny on perceived shortcomings after leaving a social situation. - Post-event processing – replay social encounters in a negative way.
- Physical symptoms during social situations:
- Blushing, sweating, trembling, and palpitations – can manifest in the form of a panic attack.
o Childhood presentations: Crying, tantrums or freezing. - Attentional biases – heightened attention to negative evaluative threat cues, and lack of attention to positive or benign cues.
What are the attentional biases associated with social anxiety disorder?
Heightened attention to negative evaluative threat cues, and lack of attention to positive cues
What physical symptoms are associated with social anxiety disorder?
- Blushing, sweating, trembling, and palpitations – can manifest in the form of a panic attack.
Describe a characteristic type of heightened anxiety behaviour in social anxiety disorder?
Anticipatory
Which identification tool is used for the diagnosis of social anxiety disorder?
3-item Mini-Social Phobia Inventory (Mini-SPIN).
What is the diagnostic assessment tool to confirm a diagnosis of social anxiety disorder?
- Social Phobia Inventory (SPIN) or the Liebowitz Social Anxiety Scale (LSAS).
What is the first line management option for social anxiety disorder?
CBT
What two models is CBT based on for the management of social anxiety disorder?
Clark and Wells Model
Or
Heimberg Model for 12 weeks
Name 5 forms of CBT for social phobia?
- Graduated exposure to social situations
- Relapse prevention
- Cognitive restructuring.
- Video feedback and systematic training.
- Education about social anxiety
What is the indication for pharmacological therapy for social anxiety disorder?
For patients who prefer pharmacological therapy over individual CBT.
What is the first line drug for social anxiety disorder?
Sertraline (starting dose - 25 mg OD, increase by 25-50mg/day)
What is the starting dose of sertraline in social anxiety disorder?
25 mg
What is the maximum dose of sertraline?
200 mg/day
Name a SNRI used in social anxiety disorder?
Venlafaxine
What is the 2nd line therapy for social anxiety disorder?
Combination CBT + SSRI therapy
OR switch to an alternative SSRI/SNRI
How long should CBT be commenced until combined with SSRI therapy?
10-12 WEEKS
If an alternative SSRI/SNRI is unsuccessful, which class of drug is indicated in social anxiety disorder?
Monoamine oxidase inhibitor
Define a panic attack:
Panic Attack: A brief and sudden episode of intense fear or apprehension – associated with a sense of impending doom.
Symptoms of panic disorder should occur by at least how many months following an uncued panic attack?
At least 1 month
What are the DSM-V symptoms associated with panic disorder?
o Palpitations
o Diaphoresis
o Trembling or shaking
o Shortness of breath
o Feeling of choking
o Chest pain or discomfort
o Nausea of GI distress
o Feeling dizzy, unsteady, light-headed or faint
o Chills
o Paraesthesias
o Derealization or depersonalisation
o Fear of losing control
o Fear of dying
Define agoraphobia
Anxiety about, and avoidance of, places or situations in which the ability to escape is perceived to be limited or embarrassing.
Agoraphobia is often co-morbid with which disorder?
Panic disorder
What is the median age of onset for agoraphobia?
20-35 years (F > M()
What is the DSM-5 criteria for the diagnosis of agoraphobia?
- Significant worry about at least two of the following situations:
o Using public transportation
o Being in an open space
o Being in enclosed spaces
o Standing in a line or being in a crowd
o Being outside of the home alone
o Uniting fear Inability to escape to a safe place Overwhelming urge to return home to safety.
o Problem situations Travelling (trains, buses, etc), queuing, supermarkets, crowds, parks.
N.B: At least 6 months of fear and anxiety, accompanied by avoidance of agoraphobia situation secondary to the anticipatory thoughts of experiencing symptoms and being unable to overcome them when exposed to it.
What is the minimum duration for agoraphobia symptoms for diagnosis?
At least 6 months
Which three scoring systems can be used to diagnose agoraphobia?
- Panic Disorder Severity Scale
- Positive PRIME-MD panic screen
- GAD-7 cute score
What is the first-line management option for panic agoraphobia?
Education, reassurance, and self-help
For mild-to-moderate agoraphobia, what type of CBT can be used?
Exposure Response Prevention
What is the first line management for moderate-to-severe panic disorder with or without agoraphobia?
CBT
What term describes the following: ‘Recurrent and persistent thoughts, urges or images experienced as intrusive or unwanted’)?
Obsessions
Which term describes repetitive mental operations or physical acts?
Compulsions
Do patients with OCD have insight?
Yes - self-recognised as a product of own mind
What is egodystonic thought?
Themes/ideas against that which the person associates with their ego
Why are compulsions performed?
Performed to reduce anxiety through irrational belief they will prevent a dreaded event
Which part of the brain is implicated in OCD?
Basal ganglia
The basal ganglia is affected by which three disorders?
Sydenham’s chorea
Encephalitis Lethargica
Tourette’s syndrome
What type of personality disorder is associated with OCD?
anakastic personality disorder
What are the common compulsions associated with OCD?
Counting, repeating words silently, ruminating, and attempting to neutralise thoughts.
What are the common obsessions associated with OCD?
Fear of contamination, need for symmetry or exactness, fear of causing harm to someone, sexual obsessions, fear of behaving unacceptable
After 12 weeks no-treatment response in CBT, which class of medication is recommended in panic disorder?
Impiramine or clomipramine
Which scoring scale is indicated in the assessment of OCD?
Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)
What is severe OCD in terms of obsessions/compulsions/day?
> 3 hours/day
What is the scoring threshold for severe OCD?
24-31
What are the OCD screening questions?
- Do you wash or clean a lot?
- Do you check the time a lot?
- Is there any thought that keeps bothering you that you would like to get rid of?
- Do your daily activities take a long time to finish?
- Are you concerned about putting things in a special order or are you very upset by a mess?
- Do these problems trouble you?
What low-intensity CBT is used for mild OCD?
Exposure and response prevention with structured self-help.
What is the first-line management for moderate OCD?
Intensive CBT including ERP or SSRI.
What SSRI options are available for OCD management?
- Sertraline, escitalopram, fluoxetine, paroxetine
What is the minimum time period for SSRI therapy in OCD?
12 weeks
What is the alternative medication to SSRI in OCD?
Clomipramine
How long should SSRI therapy be continued after remission?
12 months
What is the starting dose for SSRI therapy in OCD?
60 - 80 mg
For severe OCD what is the immediate management?
Referral to secondary care mental assessment
-Combined treatment with an SSRI and CBT
What is the risk of starting SSRI therapy in patient <25-30 years of age?
Suicide, self-harm , arrange a follow-up in a week
What are the indications for specialist assessment in OCD?
- Severe OCD
- Risk of suicide/self-harm – same day to Crisis team.
- Severe self-neglect
- Significant co-morbidity – substance misuse, severe depression anorexia nervosa, schizophrenia.
- <18 years of age
What are the complications associated with OCD?
Self-harm, suicide
Dermatitis
Reduced QoL
What are cluster A personality disorders?
Odd/eccentric
-Weird- paranoid, schizoid, schizotypal
What are the domains assessed in personality disorder?
- Cognitive-perceptual
- Affect regulation
- Interpersonal functioning
- Impulse control
What are cluster B personality disorders?
Wild
Dissocial, borderline (EUPD), histrionic, narcisstic
What are the Cluster C personality disorder?
Worried - Anakastic, anxious-avoidant, dependent
What are the REPORT criteria?
R Relationships affected [Pathological]
E Enduring [Persistent]
P Pervasive
O Onset in childhood/adolescence [Persistent]
R Result in distress [Pathological]
T Trouble in occupational/social performance [Pathological]
What are the features of paranoid personality disorder?
S Sensitive
U Unforgiving
S Suspicious
P Possessive and jealous of partners
E Excessive self-importance
C Conspiracy theories
T Tenacious sense of rights
What is the description of the following personality disorder:
A Anhedonic
L Limited emotional range
L Little sexual interest
A Apparent indifference to praise/criticism
L Lacks close relationships
O One-player activities
N Normal social conventions ignored
E Excessive fantasy world
Schizoid personality disorder
What personality disorder is described by the following features?
- Eccentricity and eccentric thoughts/ideas (Main difference between this and schizoid).
- Paranoid and bizarre ideas
- Believe in magic and fairies.
- Social withdrawal
- Cold/inappropriate affect
Schizotypal personality disorder
What is the following personality disorder?
Attention-seeking
Concerned with appearance
Theatrical
Open to suggestion
Racy and seductive
Shallow affect
Histrionic personality disorder
Attention-seeking behaviour and emotional liability is associated with which type of personality disorder?
Histrionic personality disorder
What personality disorder is marked by recurrent self-harm and explosive behaviour in addition to affective instability?
Emotionally unstable personality disorder/borderline
What type of personality disorder is associated with social avoidance, fear of rejection, and apprehension?
Avoidant personality disorder
What type of personality disorder is associated with fear of abonnement, and feelings of helplessness when alone?
Dependent personality disorder
An immature response whereby one has the inability to reconcile the good and bad in someone and only views people based on two categories: Good or all-bad (I.E often ending relationships explosively and cannot maintain relationships)
- What ego defence is this in EUPD?
Splitting
What is an immature ego defence where one assumes a different identity to deal with a situation?
Dissociation
Which mature ego defence is associated with an action that does not conflict with their egos/values/personality trait?
Sublimation
What ego defence is associated to reverting to immature behaviour in a stressful situation I.E banging a desk in frustration?
Regression
Which criteria is used to diagnose PD?
REPORT criteria
What class of medication is indicated for Cluster B personality disorders?
Antipsychotics – Reduce impulsivity and aggression
What class of medication is associated with the management of Cluster B,C personality disorders?
- Antidepressants (SSRIs) - Reduce impulsivity and anxiety
What is the first line CBT indicated for EUPD?
DBT/Dialectical behaviour therapy
Define anorexia nervosa
Anorexia nervosa is an eating disorder characterised by restriction of caloric intake –> Low body weight and intense fear of gaining weight + body weight disturbance.
What is the BMI threshold for low weight?
<18.5
What is the clinical presentation of anorexia nervosa?
- Intense fear of gaining weight
- Preoccupation with food and weight – the pursuit of thinness.
- Behaviour that interferes with weight gain
- Compensatory behaviours – self-induced purging (vomiting or use of laxatives)
o Excessive exercise
o Use of appetite suppressant medication or diuretics. - Restriction of energy intake resulting in low body weight:
- Low weight is defined as BMI <18.5.
- Psychological disturbances may include:
- Distortion of body image, with a dread of being overweight.
- Low self-esteem and a drive for perfection.
- Over-evaluation of self-worth in terms of body weight and shape.
- Amenorrhoea – Seen in low-weight girls and women.
What are the three ICD-10 diagnostic criteria for anorexia nervosa?
- BMI <17.5 (Or weight >15% less than expected)
- Deliberate weight loss
- Fear of the fat/distorted body image
BMI threshold for anorexia nervosa?
<17.5
What are the common deliberate weight loss strategies employed in anorexia nervosa?
Laxatives
Vomiting
Excessive exercise
Appetite suppressants
What endocrine dysfunction manifestations are associated with anorexia nervosa?
Amenorrhoea - women
Impotence - men
Loss of libido
Delayed puberty
What type of hair is observed in anorexia nervosa?
Lanugo hair
What sign is observed that is associated with self-induced vomiting?
Russel’s sign
What cardiovascular complications are implicated in anorexia nervosa?
Bradycardia
Postural hypotension
Arrhythmias (2nd to Hypokalaemia)
What gastrointestinal complications are associated with anorexia nervosa?
Constipation, pain (ulcers), Mallory-Weiss tears, nutritional hepatitis (low protein, raised BR, LDH, ALP)
What Msk complications are associated with anorexia nervosa?
Osteoporosis, proximal myopathy (squat test +ve), hx of fractures
What questionnaire is indicated in the screening for eating disorders?
SCOFF questionnaire
What is the first line management for eating disorders?
Refer immediately for specialist assessment to the community mental health team or CAHMS (if <18 years of age)
Which guidelines are followed for the management of adults with a suspected eating disorder?
MARISPAN guidelines
An urgent referral to what service is required for a severe suspected eating disorder?
Community eating disorder service (CEDS)
What bradycardia threshold warrants admission for suspected anorexia nervosa?
<40 beats per minute
Which test assesses for muscle power in patients with a suspected eating disorder?
Sit-up-squat-stand (SUSS) test.
Reduced muscle power on the SUSS test in a patient with a suspected ED warrants what action?
Admission
What factors of cardiovascular instability in a patient with an eating disorder warrants admission?
bradycardia <40 BPM, tachycardia on standing, prolonged QT interval or postural hypotension.
What is the first line of management for adult eating disorder following an immediate specialist assessment?
- Individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
- Up to 40 sessions over 40 weeks, with twice-weekly sessions in the first 2-3 weeks.
What adult focussed treatment for anorexia is recommended?
MANTRA (Maudsley Anorexia Nervosa Treatment for Adults) – 20 sessions.
What are the three first-line management options for confirmed anorexia nervosa in adults?
- Individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
- MANTRA (Maudsley Anorexia Nervosa Treatment for Adults) – 20 sessions.
- Specialist supportive clinical management (SSCM).
Which charities are available for patients with eating disorders?
BEAT charity, MIND NHS
What type of therapy for eating disorders is available for <18 year olds?
Anorexia-focussed Family-therapy
Which pharmacological agent is indicated for eating disorder patients with a significant pre-occupation with food?
Fluoxetine
Which three ions are significantly low in re-feeding syndrome?
Low phosphate
Low magnesium
Low potassium
Why does refeeding syndrome occur?
An intracellular shift of already low ions due to insulin release upon refeeding.
Which ion when low in refeeding syndrome presents a significant concern?
Potassium - hypokalaemia
What are the symptoms and signs associated with refeeding syndrome?
Fatigue, weakness, confusion, high BP, seizures, arrhythmia, HF.
What are the 5 questions asked in the Scoff questionnaire?
Do you make yourself SICK because you feel uncomfortably full?
Do you worry you have lost CONTROL over how much you eat?
Have you recently lost more than ONE stone in a 3-month period?
Do you believe yourself to be FAT when others say you are too thin?
Would you say that FOOD dominates your life?
What feature differentiates bulimia nervosa with anorexia nervosa?
Recurrent episodes of binge eating
Minimum period for binge eating and inappropriate compensatory behaviours for diagnosis of bulimia?
At least once a week for 3 months
What are the common Recurrent inappropriate compensators/behaviours to prevent weight gain in bulimia?
a. Self-induced vomiting
b. Misuse of laxatives, diuretics and other medications
c. Fasting
d. Excessive exercise.
Weight for bulimia nervosa?
- Weight is often within normal limits or above the weight range for age.
What are the psychological features implicated in Bulimia Nervosa?
- Over-evaluation of self-worth – in terms of body weight and shape.
- Fear of gaining weight, with a sharply defined weight threshold set by the person.
- Mood disturbance of anxiety and tension.
- Persistent preoccupation and craving for food and feelings of guilt and shame about eating.
What are the physical symptoms (4) observed in bulimia nervosa?
- Bloating, lethargy, GORD, abdominal pain, and sore throat (from vomiting)
- Russel’s sign - knuckle calluses from induced vomiting
- Dental enamel erosion
- Salivary gland enlargement
What is the difference from binge eating disorder from bulimia nervosa?
Binge eating episodes without purging pathology
In severe bulimia, an urgent referral to which service is required?
Community eating disorder (CED) service
What is the first line management for moderate bulimia nervosa?
Guided self-help, beat charity and monitor for 8 weeks
What are the features associated with severe bulimia nervosa?
Daily purging, significant electrolyte imbalance, comorbidity
What are the features associated with moderate bulimia nervosa?
Frequent binging and purging (>2 episodes/week)
What is the first line therapy for <18 year olds with bulimia?
Family therapy
What is the first line management for adults with bulimia?
Guided self-help programme (bulimia nervosa focussed)
Serotonin syndrome results in the excessive serotonergic stimulation of which two receptors?
5-HT and 5-HT2a receptors
Which anti-depressant drug is associated with the greatest risk of serotonin syndrome if taken with SSRIs?
Monoamine oxidase inhibitors
Which drugs when combined with SSRI can predispose to serotonin syndrome?
Triptans
Monoamine oxidase inhibitors
Tramadaol
St John’s Wort
- Ecstasy
- Amphetamines
- Cocaine, MDMA, LSD, Lithium
What are the symptoms of serotonin syndrome?
- Neuromuscular excitation
o Hyperreflexia
o Myoclonus
o Rigidity - Autonomic effects
o Hyperthermia (>38)
o Sweating
o Hypertension
o Tachycardia
o Dilated pupil
o Flushed skin - Altered mental status
o Confusion
o Anxiety
o Agitation
What autonomic symptoms are associated with serotonin syndrome?
o Hyperthermia (>38)
o Sweating
o Hypertension
o Tachycardia
o Dilated pupil
o Flushed skin
Which neurological signs can be elicited on examination in patients with serotonin syndrome?
- Clonus
- Inducible, spontaneous, and ocular.
Babinski’s sign
Hyperreflexia
Onset of serotonin syndrome?
Within minutes to hours after initiating a new psychopharmacologic treatment or increasing dose
What is the management for mild serotonin syndrome?
Cessation of offending agent
Which drug is prescribed to patients with moderate serotonin syndrome?
Benzodiazepines e.g., diazepam
What is the management for severe serotonin syndrome?
Emergency supportive care
- Activated charcoal (25-100 g orally as a single dose) if overdose occurred within 2 hours.
- IV sedation
- Cyproheptadine and chlorpromazine.
Define neuroleptic malignant syndrome
A life-threatening neurological emergency associated with the use of antipsychotic agents is characterised by mental status changes, rigidity, fever and dysautonomia.
What is the aetiology of Neuroleptic Malignant Syndrome
Dopamine blockade induced by antipsychotics - triggers glutamate release and subsequent neurotoxicity
Which high-potency antipsychotics are associated with Neuroleptic Malignant Syndrome?
Haloperidol
Fluphenazine
What is the clinical presentation of Neuroleptic Malignant Syndrome?
- Mental status change
- Agitated delirium with confusion.
- Catatonic signs and mutism.
- Muscular rigidity
- Generalised
- Increased tone – lead-pipe rigidity.
- Hyperthermia
- > 38 degrees.
- Autonomic instability
- Tachycardia
- Labile or high blood pressure
- Tachypnoea
- Diaphoresis
What are the first-line laboratory investigations indicated for neuroleptic malignant syndrome?
Serum creatine kinase
Why is serum creatine kinase raised in neuroleptic malignant syndrome?
Due to rhabdomyolysis
What is the management for neuroleptic malignant syndrome?
Stop anti-psychotic drug
Supportive fluids and dialysis to minimise renal failure
What drug is prescribed in patients with neuroleptic malignant syndrome?
Dantrolene and bromocriptine
Which personality disorder is associated with conduct disorder?
Antisocial personality disorder
Which gender is predominantly affected in conduct disorder?
Male
What is the median age of onset of conduct disorder?
11 years
What are the risk factors of conduct disorder?
Risk factors:
* Low socioeconomic status
* Deprived living
* Children in the care system
* ADHD
* Substance misuse
* Male
What is the minimum period duration required for the diagnosis of conduct disorder?
3 out of the 15 behavioural manifestations in the past 12 months, and at least one in the past 6 months.
What four domains are assessed by the DSM-5 criteria in conduct disorder?
Aggression against people and animals
Destruction of property
Deceitfulness or theft
Serious violation of rules
What is the difference between oppositional-defiant disorder and conduct disorder?
ODD associated <10 years of age and defiant behaviour to authority without aggression/destruction
What is the first line of management for conduct disorder?
Parent training
Group parent training
-Webster-Stratton, Triple-P models
A referral to CAMHS is indicated by which criteria for conduct disorder?
- A co-existing mental health problem (depression, PTSD)
- Neurodevelopmental condition (ADHD)
- Learning difficulty
- Substance misuse.
What are the risk factors for delirium?
sk Factors:
* Age 65 years or older
* Cognitive impairment and/or dementia
* Current hip fracture
* Severe illness
* Current history of alcohol abuse
* Untreated vision and hearing loss
* Infection – UTI, RTI
* Medication (Anti-Ach, steroids, opiates)
* Encephalitis
* Constipation
* Urine retention
* Stroke
* Hyponatremia
Define hypoactive delirium
Hypoactive delirium: Withdrawal, slow responses, reduced mobility, and movement, worsened concentration, and reduced appetite.
Which assessment method is used for delirium?
Confusion Assessment Method (CAM).
Which medication is prescribed to manage agitation in delirium patients?
Low-dose haloperidol 0.5-1mg
Which class of drugs should be avoided in patients with conduct disorder?
- Avoid anticholinergics.
What are the four different types of dissociative disorder?
- Dissociative identity disorder (DID)
- Dissociative amnesia
- Dissociative fugue
- Depersonalisation/derealisation disorder.
What are the risk factors for dissociative disorder?
- Chronic stress during adolescence.
- Witnessing or experiencing acute trauma.
- Severe childhood sexual abuse is a predictor of dissociative disorders.
Define dissociative amnesia?
- Loss of autobiographic memory for previous experiences or before a certain point in time.
What is dissociative fugue?
- Dissociative amnesia + sudden and unplanned purposeful travel away from one’s home.
What defines the following ‘Patients appear to possess two or more distinct identities or personality states, associated with the patient’s consciousness, perception, thoughts, and actions’
Dissociative Identity Disorder (DID)
Define depersonalisation disorder
- The patient believes that they have been altered in some way or that they are no longer real.
What investigation differentiates between a dissociative convulsion with a real one?
Serum prolactin (normal)
What is the first line management for a paracetamol overdose if ingested over 1 hour?
N-acetylcysteine (NAC)
If there are signs of jaundice, hepatic tenderness and raised ALT in a paracetamol overdose (>24 hours), what is the first line management?
N-acetylcysteine
First line management of paracetamol overdose if within 1 hour of consumption?
Activated charcoal
What is the cut off for a liver transplant in paracetamol overdose?
Prothrombin time >100 s
What hepatic complication is implicated with a paracetamol overdose?
Hepatic necrosis
What is the clinical presentation of an aspirin overdose?
- Hyperventilation
- Tachypnoea, hyperpnea, and tachycardia.
- Tinnitus
- Deafness
- Vasodilation
- Sweating
At what salicylate concentration results in toxicity?
2.2-3.6 mmol/L
What is the management for an aspirin overdose?
Urinary alkalinization with IV bicarbonate.
Consider haemodialysis
What type of features are associated with TCA overdose?
Anticholinergic features
List the anticholinergic features associated with TCA overdose?
- Dry mouth
- Seizures
- Coma
- Cardiac conduction defects
- Arrhythmias, hypothermia, hypotension.
- Hyperreflexia
- Convulsions
- Respiratory failure
Dilated pupils
Downregulation of parasympathetic system
Which ECG changes are observed in TCA overdose?
- Sinus tachycardia
- Widening of QRS complexes
- QT interval prolongation.
A QRS interval of what > is associated with an increased risk of seizures?
> 100 ms
What is the first line management for TCA overdose?
Intravenous bicarbonate
What are the symptoms associated with SSRI overdose?
Nausea, vomiting, agitation, tremor.
* Nystagmus
* Drowsiness
* Sinus tachycardia
* Serotonin syndrome
What ECG abnormality is associated with citalopram?
QT prolongation
Within how many hours post-SSRI overdose can necessitate 50 g of oral activated charcoal?
4 hours
What is the management of QRS prolongation in SSRI overdose?
Bicarbonate
What are the features associated with a beta-blocker overdose?
Bradycardia, hypotension, syncope.
* Drowsiness
* Confusion
* Hallucinations
* Convulsions.
Which ECG finding is associated with beta-blocker overdose?
PR prolongation
What is the management for beta-blocker overdose?
Glucagon injection to manage symptomatic hypoglycaemia + IV dextrose
What pupillary defect is associated with opioid overdose?
Pinpoint pupils (miosis)
Respiratory complication associated with opioids?
Respiratory depression
ECG finding associated with opioid overdose?
QRS prolongation
Management of opioid overdose (first line)?
Naloxone
Management of opioid overdose with retained packages?
Whole bowel irrigation
What are the clinical features associated with benzodiazepine overdose?
Drowsiness
* Dysarthria
* Ataxia
* Nystagmus
* Respiratory depression
2 investigation performed for suspected benzodiazepine overdose?
Urine testing - BZD screen
ABG
Management for benzodiazepine overdose?
Flumazenil
What are the auditory hallucinations associated with schizophrenia?
Third person or running commentary
What are delusions of reference?
Occurrences whereby a special message is delivered to the individual
What are the common bizarre delusions associated with schizophrenia?
Persecutory/paranoid delusions
Which term describes thoughts that are being shared with others?
Thought broadcast
Which term describes thoughts being inserted and felt to be alien?
Thought insertion
What term describes a patient becoming increasingly further off-topic without appropriately answering a question?
Tangentiality
Which speech disorder is associated with ‘Eventually answers a question, but in a markedly roundabout manner’?
Circumstantial speech
Which speech disorder is associated with ‘Suddenly switches topics without any logic or segue’?
Derailment
Which term describes the following ‘The creation of new, idiosyncratic words’?
Neologisms
Which speech disorder term describes ‘Words are thrown together without any sensible meaning’?
Word salad
What are the symptoms associated with simple schizophrenia?
Negative Symptoms (Simple):
- Social withdrawal
- Demotivation
- Self-neglect
o Anhedonia
o Alogia
- Flat affect
o Incongruity/blunting of affect
- Catatonia
What are Schneider’s first-rank symptoms?
Delusions
Passivity
Thought disorder - insertion, withdrawal, broadcasting
Auditory disorder - thought echo, 3rd person voice, running commentary
What type of schizophrenia is characterised by disorganised symptoms, bizarre motor activity and emotional responses?
Hebephrenic
What type of schizophrenia is characterised by negative symptoms?
Simple
What rating scale is used to assess for schizophrenia and psychosis?
Brief psychiatric rating scale
What is the first-line approach for managing and aggressive and violent patient?
verbal de-escalation
What is the next line management option following verbal de-escalation for an aggressive patient?
Rapid tranquillisation
What drug is indicated for the rapid tranquillisation?
Intramuscular lorazepam
What is the urgent management option for patients with schizophrenia and acute psychosis?
Crisis resolution team and home treatment team
What is the community support intervention for patients with first episode of psychosis?
Early intervention in psychosis team
Which dopamine pathway is associated with positive symptoms?
Mesolimbic
Which dopamine pathway is implicated with negative symptoms?
Mesocortical
THe mesocortical pathway connects cell bodies in the ventral tegmental area to what?
Prefrontal cortex
Which side effects are associated with the nigrostriatal pathway?
Extrapyramidal side effects
Extrapyramidal side effects is associated with which dopamine pathway?
Nigrostriatal pathway
Which dopamine pathway is associated with hyperprolactinaemia?
Tuberoinfundiable
Typical antipsychotic medications block which specific dopamine pathway that results in hyperprolactinaemia symptoms?
Tuberoinfundiable pathway
What are the clinical signs and symptoms of hyperprolactinaemia?
Altered menstural period
Weight gain, osteoporosis
Risk of breast and pituitary cancer
Gynaecomastia.
Which ethnicity is associated with an increased risk of schizophrenia?
Black Caribbean / African 4-6x higher
Which adverse life experiences are associated with an increased risk of schizophrenia?
sexual or physical abuse
The mesocortical pathway is associated with types of symptoms?
Negative symptoms
What is the first line management for schizophrenia?
6 weeks of atypical antipsychotic + CBT
Which atypical anti-psychotic is associated with a reduced side effect profile?
Aripiprazole
Which atypical anti-psychotic is associated with increased weight gain?
Olanzapine
Name atypical anti-psychotics
Risperidone
Olanzapine
Quetiapine
Aripiprazole
What is the management option for non-compliant schizophrenia?
Once-monthly IM depot injection (i.e., zuclopenthixol decanoate 200mg depot injection; ‘Clopixol’)
What is the minimum duration for atypical antipsychotic trial in the management of schizophrenia?
6 weeks
Following 6 weeks of atypical antipsychotic management, what is the second line option?
Change to a different atypical or a try a typical antipsychotic
Despite two 6 week trials of different antipsychotic medication, what is the next-line option?
Clozapine
Dopamine receptor antagonists act on which specific dopamine pathway?
Mesolimbic pathway
Which specific cerebral region is associated reward, motivation, cognition and version?
Ventral tegmental area
Dopamine receptor antagonists are associated with an increased risk of what in the elderly?
Stroke
VTE
Acute dystonia is associated with what 3 clinical manifestations?
Torticollis
Oculogyric crisis
Laryngeal dystonia
Torticollis and oculogyric crisis is associated with what type of extrapyramidal side effect?
Acute dystonia
What is the management of acute dystonia?
Procyclidine (5-10 mg OD).
What term describes an involuntary, painful, sustained muscle spasm resulting in unilateral neck twisting?
Torticollis
Which disorder of acute dystonia is associated with Eye twists up and cannot look down.
Oculogyric crisis
What term describes ‘o An unpleasant subjective feeling of restlessness; patients often must pace about or jiggle their legs to cope with it’?
Akathisia
What is the management of akathisia?
Decrease dose/change antipsychotic – Add propranolol or benzodiazepines.
What term describes ‘o A triad of Resting tremor, rigidity (experienced as stiffness), and bradykinesia. Patients may have mask-like facies and a shuffling gait’?
Parkinsonism
Drug-induced Parkinsonism is associated with what type of tremor?
Bilateral tremor
What is the management for drug-induced Parkinsonism?
Decrease/change antipsychotic – prescribe anticholinergic – procyclidine.
What term describes the following:
‘Rhythmic involuntary movements of the mouth, face, limbs, and trunks. Grimacing, make chewing and sucking movements with their mouth and tongue?
Tardive Dyskinesia
What is the management option for tardive dyskinesia?
Tetrabenazine
What are the four types of extrapyramidal side effects?
Acute dystonia
Akathisia
Parkinsonism
Tardive dyskinesia
What are the features are associated with tardive dyskinesia?
Protrusion and rolling of the tongue
Sucking and smacking movements of the lips
Chewing motion
Facial dyskinesia
Involuntary movements of the body and extremities
What are the clinical features associated with akathisia?
Restlessness
Trouble standing still
Paces the floor
Laryngeal spasms are associated with what type of extrapyramidal side effectt?
Acute dystonia
Quetiapine, olanzapine, risperidone is associated with what type of side effects?
Sedation
Weight gain
Hyperglycaemia
Anticholinergic side effects
EPSE
Which specific atypical antipsychotic is associated with an increased risk of weight gain?
Olanzapine
What is the most common side effect associated with atypical anti-psychotics?
Weight gain and metabolic syndrome
What are the anticholinergic side effects associated with atypical anti-psychotics?
a. Dry mouth and eyes
b. Blurred vision
c. Urinary retention
d. Constipation
e. Postural hypotension
Significant hyperprolactinaemia symptoms can be mitigated with which alternative atypical anti-psychotics?
switch to aripiprazole
What class of drug is aripiprazole?
Partial dopamine agonist
Which electrophysiological abnormality is associated with quetiapine?
QT prolongation
QTc prolongation can result in what complication?
Polymorphic VT (TDPs) and a loss of cardiac output.
What side effects are associated with clozapine?
Agranulocytosis (1%) – Neutropenia (eosinophilia, lymphopenia, neutropenia leucocytosis) Weekly FBC and prior to initiating management.
Reduced seizure threshold
Severe constipation
Myocarditis
Interacts with lithium
Paradoxical hypersalivation
Advice for smoking cessation to clozapine dose?
Adjust dose - increase if immediate cessation
What is the main significant complication associated with clozapine?
Agranulocytosis
Why is metabolic syndrome associated with atypical antipsychotics?
Atypical antipsychotics have a propensity to induce hyperglycaemia and subsequent impaired glucose tolerance.
* Hypertension
* Obesity
* Diabetes – Olanazapine.
What frequent monitoring investigation is implicated in clozapine management?
FBC
What basic observations are associated with atypical antipsychotics?
o Weight and waist circumference (weekly for 6 weeks, at 12 weeks, annual thereafter)
Weight, waist circumference, pulse and BP.
What preliminary blood tests are implicated prior to initiating atypical antipsychotics?
FBC, U&Es, LFTs, fasting BM, HbA1c, lipid profile, prolactin (more frequent if on clozapine).
Definition of schizoaffective disorder?
Schizoaffective disorder is characterised by both combined features of schizophrenia concurrent with mood symptoms (depression or mania), lasting for a considerable part of a 1-month period.
* Depressive type is more common in older patients
* Bipolar type = young patients
What is the first-line management for schizoaffective disorder?
Fluoxetine (SSRI) + olanzapine (antipyshocitc)
What is the 2nd line management for schizoaffective disorder?
Lamotrigine
What type of delusional disorder is characterised by the belief that another person is secretly in love with them?
Erotomanic (De Clereambault syndrome)
What type of delusional disorder is associated with the belief of ‘special prominence or talent’?
Grandiose
What type of delusional disorder is associated with the belief that a spouse or partner is unfaithful?
Orthello syndrome
What are the characteristic features of Orthello syndrome?
o Accuses the spouse - Aggressive, threatening and possibly violent behaviour (homicide and suicide).
o Delusion of infidelity.
What type of delusional disorder is associated with the following description
‘Belief that a familiar person has been replaced by an exact double – an impostor?
Capgras
What type of delusional disorder is characterised by the following description?
Belief that a complete stranger is actually a familiar person already known to one
Fregoli
Capgras syndrome is associated with what?
Belief that a familiar person has been replaced by an exact double – an impostor.
Fregoli syndrome is associated with what?
Belief that a complete stranger is actually a familiar person already known to one.
What nihilistic delusional disorder is associated with denial or self-existence?
Cotard syndrome
Which delusional disorder is associated with delusions of infestation?
Ekbom syndrome
Ekbom syndrome is associated with what type of delusions?
Delusions of infestation
Which medically unexplained symptom disorder is associated with persistent pre-occupation with a single problem (often associated with cancer)?
Hypochondrial Disorder
Which medically unexplained symptom disorder is associated with symptoms of objective autonomic arousal e.g., palpitations, sweating, flushing, tremor?
Somatoform Autonomic Dysfunction
Which syndrome is associated with the intentional production of physical or psychological symptoms (feigning)?
Munchausen’s syndrome
Factitious disorder
What type of behaviours is associated with feigning symptoms?
- Deceptive behaviours – falsify symptoms and disease.
- Fabrication of illness
- Forging medical records
- Tampering with medical instruments
What is the difference between malingering and factitious disorder?
Malingering - Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain.
What disorder is associated with a loss of motor or sensory function?
Conversion disorder
What are the clinical manifestations associated with conversion disorder?
- La belle indifference.
- Nonepileptic seizures
- Weakness and paralysis
- Abnormal movement
- Speech disturbances
- Globus sensation
- Visual symptoms
What is the management plan for medically unexplained symptoms?
1st line: Reassure and Explain
* Broaden clinical agenda from a physical cause to a physical + psychological cause.
o 2nd: Clear about negative clinical findings and links symptoms to psychological aetiology.
Acknowledge psychosocial distress
Elicit childhood experience of illness
- 3rd: Explain you’ll conduct no further investigations
- 4th: Emotional support:
o Encouraging coping strategies
o Letting go of inappropriate sick role
o Involve family who may be reinforcing behaviour
Which protein is implicated in Alzheimer’s dementia?
Beta-amyloid protein
Beta-amyloid protein deposition affects which part of brain in Alzheimer’s dementia?
Hippocampus
What protein implicated in Alzheimer disease is associated with microtubule assembly?
Tau protein
Hyperphosphorylation of tau forms what?
neurofibrillary tangles
What forms extracellular plaque deposits in Alzheimer’s dementia?
Beta-amyloid
What protein forms intracellular neurofibrillatory tangles?
Tau
What psychosocial risk factors are associated with Alzheimer’s dementia?
Low IQ
Poor educational level
Which congenital chromosomal disorder is associated with an increased incidence of Alzheimer’s dementia?
Down’s syndrome
What type of memory impairment is spared in early stage Alzheimer’s dementia?
Immediate recall
What type of memory loss is associated with early-stage Alzheimer’s dementia?
Anterograde
What are the four A’s associated with Alzheimer’s?
- Amnesia Recent memories lost first; disorientation occurs early
- Aphasia Aphasia in finding correct words (Broca’s), speech muddled/disjointed
- Agnosia Typically “Visual” (i.e. prosopagnosia – recognising faces)
- Apraxia Typically “Dressing” (skilled tasks, despite normal motor functioning)
What three behavioural changes are associated with Alzheimer’s disease?
- Behavioural changes:
o Mood changes
o Apathy
o Memory impairment
Which drugs are contraindicated in the management of Alzheimer’s dementia?
- Do not use antipsychotics to manage long-term (Risperidone has a short-term licence)
What bedside cognitive testing is associated with Alzheimer’s dementia?
Folstein Mini-Metal State Examination
SLUMS examination
What MMSE score cut-off is associated with Severe cognitive impairment?
<18
What MMSE score threshold is associated with mild cognitive impairment?
18-23
What is the AMTS cut-off for cognitive impairment?
<7
What tests/investigations are implicated as part of the dementia screen?
TFTs (hypothyroid cognitive decline)
LFTs (Korsakoff’s)
U&Es and dipstick (infection, diabetes)
HbA1c (diabetes)
Vitamin B12 and folate
FBC - Anaemia
What is the first line referral recommendation for patients with suspected reversible causes of cognitive decline and suspected dementia?-
Specialist dementia diagnostic service (memory clinic or community old-age psychiatry)
What is a cause of rapidly-progressive dementia?
Creutzfeldt-Jakob disease
What further investigations should be performed in patients whereby a dementia diagnosis is uncertain?
- FDG-PET
What is the first-line investigation for a patient with suspected CJD?
CSF examination
What MRI feature is associated with Alzheimer’s dementia?
Hippocampal atrophy
What class of drug is the first line management for Alzheimer’s
Acetylcholinesterase (AChE) inhibitor
Name 3 examples of AChE inhibitors
- Donepezil
- Galantamine
- Rivastigmine
Which drug is second-line if AChE are contraindicated in Alzheimer’s?
Memantine monotherapy
What drug is indicated for severe Alzheimer’s disease?
Memantine monotherapy
What class of drug is memantine?
NMDA (Glutamate) partial receptor agonist
Frequency of follow-up in Alzheimer’s dementia patients?
Every 6 months
Driving advice for Alzheimer’s dementia?
Inform the DVLA and insurers
Which drugs are absolutely contraindicated in Alzheimer’s dementia?
anticholinergics (block ACh from binding), beta-blockers, NSAIDs, muscle relaxants
What type of memory loss is associated with depressive pseudodementia?
Global memory loss + deficits in executive function, speech and language
What is the 2nd most prevalent type of dementia?
Vascular Dementia
What are the risk factors for Vascular Dementia?
Risk factors
* Advanced age
* Hypertension, diabetes, hypercholesterolaemia
* Lower physical activity
* Low or high BMI
* Smoking
* Coronary artery disease
* Atrial fibrillation.
What is the pattern of cognitive decline for vascular dementia?
Stepwise cognitive decline
What are the clinical features associated with vascular dementia?
o 1st: Emotional and minor personality changes (labile emotion – tearful Elation).
Difficulty solving problems – Frontal cognitive syndrome
Apathy
Disinhibition – Frontal cognitive syndrome
Poor attention
Diminished processing of information
Retrieval memory deficit
o 2nd: Cognitive deficit
What is the management for vascular dementia?
Daily aspirin
Reduce risk factors (exercise, reduced EtOH intake, HTN, smoking cessation, AF management, DM control).
Which type of dementia is associated with Parkinsonism?
Lewy-body dementia
Which type of dementia is associated with REM sleep disorder?
Lewy-body dementia
What are lewy bodies?
Eosinophilic intracytoplasmic inclusions
Which part of the brain is affected Lewy-Body dementia?
Cingulate gyrus; deep cortical layers
What type of hallucinations are associated with Lewy-body dementia?
Lilliputian hallucinations.
What are the main features of Lewy-body dementia?
Recurrent visual hallucinations
Fluctuating confusion with marked variations in altertness
Rapid eye movement (REM) sleep behaviour disorder
Motor features of Parkinsonism
What is parasomnia?
Characterised by dream enactment
What are the motor features of Parkinoism?
Bradykinesia
Rest tremor
Anosmia
Antipsychotic sensitivity
Rigidity
Frequent falls
What investigation is indicated in Lewy- body dementia?
I-FP-CIT SPECT
What is the first line management of lewy-body dementia?
Donepezil or rivastigmine
What medication is prescribed to manage sleep disturbance in Lewy-body dementia?
Clonazepam
What protein is implicated FTD?
Tau
What are Pick’s bodies?
Pick’s bodies (hyperphosphorylated tau)
What is hallmark feature is FTD?
Progressive personality and behaviour change early in the disease course.
What is common clinical subtype FTD?
Behavioural variant
What personality features are implicated frontotemporal dementia?
Disinhibition
Apathy and loss empathy
Hyperorallity and dietary changes
Cravings and binge eating is associated with which type of dementia?
Frontaltemporal dementia
What is the pharmacological management of FTD?
anti-depressants (do not prescribe AChE inhibitors)
What is the pharmacological management for agitation, irritability and restlessness in patients with FTD?
Benzodiazepines (Short-acting - lorazepam)
What are the CT changes observed in Vascular dementia?
Multiple lucencies atrophy
What screening questionnaire is used to assess learning disability?
WAIS (III) – (Wechsler Adult Intelligence Scale) – Verbal IQ + Performance IQ = Full Scale IQ
What medication is prescribed to support poor sleep-wake cycles?
Melatonin
What are the three core symptoms of depression?
Anhedonia
Low Mood
Anergia
Minimum duration of symptoms for the diagnosis of depression?
2 weeks
What is Beck’s cognitive triad of depression?
Beck’s Cognitive Triad of Depression:
1. Worthlessness
2. Hopelessness
3. Helplessness
What are the adjunctive symptoms of depression?
Insomnia/early waking
Poor concentration
Increased or decreased appetite/weight
Suicidal thoughts or acts
Agitation or slowing of movements
Guilt or self-blame
Reduced libido
Nihilistic delusions
Which medications are associated with causing depression?
- Steroids
- COCP
- Beta-blockers (propranolol)
- Statins
- Ranitidine
- Retinoids
- HIV Medications
What are the organic differentials of depression?
- Hypothyroidism
- Hypercalcaemia
- Cushing’s disease
- Vitamin B12/D deficiency
- Obstructive sleep apnoea
- Anaemia
- Alzheimer’s dementia
What rating scale is used to screen depression?
PHQ-9
What is the maximum score for the PHQ-9 questionnaire?
27
What is the threshold for moderate-severe depression on the PHQ-9 questionnaire?
> 16
What depression scale is used postnatally?
Edinburgh postnatal depressions cale
What depression scale is indicated for inpatients?
Becks Depression inventoryI-II
What is the first line management for uncomplicated and brief depression in children?
Active monitoring and supportive care for 6 weeks (2-weeks and follow-up)
What self-help charities are available for children and young people with depression?
Mind.org
Youngminds.org
What is the management of moderate-to-severe depression in children?
Refer to CAMHS - family based interpersonal therapy, family therapy or individual CBT
If there is a significant risk of suicide, what service should be referred?
Crisis Resolution and Home Treatment Team
Which anti-depressant drug is indicated for the management of depression in young children?
Fluoxetine
What is step 1 of adult depression management?
Watchful waiting with follow-up in 2 weeks - education on sleep hygiene, exercise, self-help, and support
What is step 2 of depression management in adults (mild-to-moderate depression)?
Low-intensity psychological interventions - individual-guided self, help based on CBT
Computerised CBT
Structured group physical activity programme
What is step 3 for adult depression (Persistent sub-threshold depressive symptoms or mild-to-moderate depression with inadequate response or moderate-to-severe depression)?
Medication + CBT
What are the examples of high-intensity of psychological interventions?
Individual CBT
Interpersonal Therapy/IPT
What is the first-line management for moderate-to-severe depression?
Medication, high-intensity psychological interventions
What is the management for unresponsive severe and complex depression with risk to life?
ECT
What is the first-line anti-depressant medication in adults with depression?
50 to 200 mg Sertraline (50 mg increase every 2 weeks; over 6 weeks)
How many trials of SSRI are required prior to switching to 2nd line?
2
What is the second line management for depression following an initial 6w trial of sertraline?
Switch to SNRI/alternative SSRI
What class of drug is duloxetine?
SNRI
Name 2 SNRIs
venlafaxine, duloxetine
Which anti-depressant is implicated to improve symptoms of insomnia and appetite reduction?
Mirtazapine
What class of drug is mirtazpine?
alpha2-adrenoreceptor antagonist
Which drugs should be given with SSRIs + NSAIDs?
PPI prophylaxis for gastric ulcers
After starting anti-depressant medication, when should a patient with a low-suicide risk be reviewed?
After 2 weeks, and then every 2-4 weeks thereafter for 3 months
In patients <30 years of age starting on anti-depressant medication, when should they be reviewed?
After 1 week
Duration of AD tapered reduction?
4-week tapered reduction
What class of drug is sertraline?
Selective serotonin re-uptake inhibitors
Which receptors are affected by SSRIs?
Serotonin/5-HT
What is the minimum period of a drug to be continued following remission of the first episode of depression?
6 months
Triptans and SSRIs can cause what effect?
Serotonin syndrome
Name 5 SSRIs
- Escitalopram
- Fluoxetine
- Sertraline
- Paroxetine
- Citalopram
Which anti-depressant class is recommended in patients with underlying cardiovascular disease- post-MI?
Sertraline
Citalopram is associated with what ECG abnormality?
QT prolongation
What investigation should be performed prior to citalopram administration?
ECG - calculate the QT interval
What is the maximum dose of citalopram?
40 mg
Citalopram is contraindicated in what congenital condition?
Congenital long-QT syndrome (>440 ms)
What are the gastrointestinal side effects associated with SSRI therapy?
Weight gain
Nausea and vomiting
Diarrhoea
Headache
Dyspepsia
Increased risk of gastrointestinal bleeding (contraindicated with aspirin, NSAIDs and DOACs)
What are the sexual side effects associated with SSRI therapy?
Erectile dysfunction
Which electrolyte abnormality is associated with SSRI therapy?
Hyponatraemia
When switching Fluoxetine to an alternative SSRI, what is the switching regimen?
Reduce the dose of 2 weeks and wait 4-7 days after stopping fluoxetine
When switching SSRI to SSRI, what is the protocol?
Immediate switch or cross-taper dose
Why should fluoxetine be ceased for at least 4-7 days prior to starting an alternative SSRI?
Fluoextine has a long half-life
What are the discontinuation symptoms associated with a sudden cessation of SSRI therapy?
- Flu-like symptoms
- Insomnia
- Restlessness
- Mood swings
- Sweating
- Diarrhoea, abdominal cramps, vomiting
- Ataxia – Unsteadiness
- Paraesthesia – shocks, tingles.
What investigation monitoring is required for SNRI therapy?
Blood pressure monitoring
What are the side effects associated with SNRIs?
Constipation
Hypertension
Raised cholesterol
Clomipramine is associated with what class of anti-depressant?
Tricyclic Antidepressants
Name 2 types of Tricyclic Antidepressants
Amitripyline, and clomipramine.
Which class of drug should not be prescribed alongside TCAs?
Monoamine oxidase inhibitors
What are the side effects of TCAs?
Side effects:
* Thrombocytopenia
* Cardiac (arrhythmias, MI, stroke, hypotension)
* Anticholinergic side effects:
- Tachycardia
- Urinary retention
- Dry mouth
- Blurry vision
- Constipation
* Seizures
* Hyponatremia
What anticholinergic side effects are associated with TCAs?
Tachycardia
Urinary retention
Dry mouth
Blurry vision
Constipation
What type of incontinence is associated with TCA overdose?
Overflow incontinence
Name a Noradrenergic and specific serotonin antidepressant
Mirtazpine
What are the main side effects of mirtazapine (3)?
Sedation
Increased appetite/weight gain
Oedema
What type of reaction is associated with monoamine oxidase inhibitors?
Tyramine ‘cheese’ reaction
Name tyramine rich foods:
Cheese
Red meat
Wine
Name a monoamine oxidase inhibitor
Phenelzine, isocarboxacid, selegiline, tranylcypromine.
Selegiline is what class of drug?
Monoamine Oxidase Inhibitor
What are the symptoms of a tyramine cheese reaction?
Hypertensive crisis
What is considered as low-risk alcohol consumption (in terms of units/week)?
<14 units/week
What is considered hazardous drinking (in terms of units/week)
15-35 units/week
What is considered harmful drinking pattern (units/week)?
> 35 units/week (or 6 units/day)
Which type of receptors are increased in alcohol withdrawal?
NMDA-type glutamate receptors
Which type of receptors are decreased in alcohol withdrawal?
Inhibitory GABA
Symptoms of uncomplicated alcohol withdrawal begin when (e.g., tremor, sweating, tachycarida, psychomotor agitation)?di
4-12 hours after last drink
At 4-12 hours after the last drink, what symptoms occur?
Coarse tremor, sweating, insomnia, tachycardia, N&V, psychomotor agitation, anxiety, hallucination (transitory visual, tactile to auditory), alcohol craving.
At what period of time since the last drink do seizures typically occur?
36 hours since last drink
Type of seizures associated with alcohol withdrawal?
Grand-mal seizures
When does delirium tremenes occurs since last drink?
48-72 hours since last drink
What are the signs and symptoms of delirium tremens?
Disorientation, anterograde amnesia, psychomotor agitation, hallucinations (Lilliputian hallucinations of little people or animals), hour-by-hour fluctuations (worse at night).
Which questionnaire is used to screen for alcohol use?
CAGE questionnaire
What are the four questions in the CAGE questionnaire?
- Have you tried to cut it down?
- Have you ever been annoyed by people suggesting that you have a problem with your drinking?
- Have you ever felt guilty about drinking?
- Have you ever needed a drink to get you going in the morning – eye-opener?
What rating scale is used to assess for the severity of alcohol dependence?
AUDIT (Alcohol Use Disorders Identification Test)
What threshold score is used for second-line assessment AUDIT alcohol dependence questionnaire?
> 20
What score is associated with low risk alcohol use (AUDIT)?
0-7
Which assessment method is used to assess for the scale of severity of withdrawal?
CIWA-AR (Clinical Institute Withdrawal Assessment of Alcohol)
Which screening is a shortened-4 question version of AUDIT, for use in A&E?
FAST
What is the first line acute management for alcohol withdrawal?
Oral chlordiazepoxide ± IV/IM thiamine / Pabrinex – reducing dose.
Admission indications for alcohol withdrawal?
- Acute alcoholic withdrawal symptoms
- Wernicke’s encephalopathy (ataxia, ophthalmoplegia, confusion).
What is the inpatient drug choice for alcohol withdrawal?
Oral lorazepam ± IV/IM thiamine / Pabrinex – rapid-reducing dose.
What is the first line drug management following detox?
Acamprosate or naltrexone
How are alcohol withdrawal seizures managed?
IV lorazepam
How is delirium tremens managed?
Oral lorazepam AND IV/IM thiamine/Pabrinex (vitamin B1).
Management of Wernicke’s encephalopathy?
IV thiamine/pabrinex
Which drug reduces the craving for alcohol by enhancing GABA transmission?
Acamprosate
Which drug results in avoidance of alcohol-based products?
Disulfiram
