Psychiatry

Question 1

How could you screen for depression?

Answer 1

The following two questions can be used to screen for depression

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

A ‘yes’ answer to either of the above should prompt a more in depth assessment.

Question 2

which two tools can be used to assess depression?

Answer 2

HAD
PHQ

Question 3

HAD
-How many questions?
-how is this scored?

Answer 3

Hospital Anxiety and Depression (HAD) scale
consists of 14 questions, 7 for anxiety and 7 for depression
each item is scored from 0-3
produces a score out of 21 for both anxiety and depression
severity: 0-7 normal, 8-10 borderline, 11+ case
patients should be encouraged to answer the questions quickly

Question 4

PHQ-9
-How does this work?
-how many items?
-what does this include?

Answer 4

Patient Health Questionnaire (PHQ-9)
asks patients ‘over the last 2 weeks, how often have you been bothered by any of the following problems?’
9 items which can then be scored 0-3
includes items asking about thoughts of self-harm

Question 5

How is depression grouped? How does NICE categorise?

Answer 5

Traditionally, depression severity has been grouped under 4 categories (subthreshold, mild, moderate and severe). The updated NICE guideline uses a simpler 2 category definition of depression: less severe or more severe depression.

Less severe depression encompasses subthreshold and mild depression, and more severe depression encompasses moderate and severe depression. Thresholds on validated scales were used in this guideline as an indicator of severity
a score < 16 on the PHQ-9: less severe depression
a score of ≥ 16 on the PHQ-9: severe depression

The DSM-5 also provides criteria for diagnosing major depressive disorder (MDD), commonly referred to as depression.

Question 6

Describe DSM 5 criteria for major depressive disorder

Answer 6

Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)

Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).

Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)

Insomnia or hypersomnia nearly every day.

Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).

Fatigue or loss of energy nearly every day.

Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).

Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).

Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Question 7

Give treatment options for less severe depression

Answer 7

Treatment options, listed in order of preference by NICE
-guided self-help
-group cognitive behavioural therapy (CBT)
-group behavioural activation (BA)
-individual CBT
-individual BA
-group exercise
-group mindfulness and meditation
-interpersonal psychotherapy (IPT)
-selective serotonin reuptake inhibitors (SSRIs)
-counselling
-short-term psychodynamic psychotherapy (STPP)

Question 8

Give treatment options of more severe depression

Answer 8

Treatment options, listed in order of preference by NICE
-a combination of individual cognitive behavioural therapy (CBT) and an antidepressant
-individual CBT
-individual behavioural activation (BA)
-antidepressant medication
selective serotonin reuptake inhibitor (SSRI), or
serotonin-norepinephrine reuptake inhibitor (SNRI), or
another antidepressant if indicated based on previous clinical and treatment history
-individual problem-solving
-counselling
-short-term psychodynamic psychotherapy (STPP)
-interpersonal psychotherapy (IPT)
-guided self-help
-group exercise

Question 9

How do you switch from citalopram, escitalopram, sertraline or paroxetine to another SSRI?

Answer 9

Switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI
the first SSRI should be withdrawn* before the alternative SSRI is started

Question 10

How do you switch from fluoxetine to another SSRI?

Answer 10

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

Question 11

How do you switch fro an SSRI to a tricyclic antidepressant?

Answer 11

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

Question 12

How do you switch from citalopram, escitalopram, sertraline or paroxetine to venlafaxine?

Answer 12

Switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine
cross-taper cautiously. Start venlafaxine 37.5 mg daily and increase very slowly

Question 13

Depression in older people:
What are the features?
What is the management

Answer 13

Older patients are less likely to complain of depressed mood

Features
physical complaints (e.g. hypochondriasis)
agitation
insomnia

Management
SSRIs are first line (adverse side-effect profile of TCAs more of an issue in the elderly)

Question 14

ECT
-what is this used for?
-Give 5 short term side effects
-Give 1 long term side effect

Answer 14

Electroconvulsive therapy is a useful treatment option for patients with severe depression refractory to medication (e.g. catatonia) those with psychotic symptoms. The only absolute contraindications is raised intracranial pressure.

Short-term side-effects
headache
nausea
short term memory impairment
memory loss of events prior to ECT
cardiac arrhythmia

Long-term side-effects
some patients report impaired memory

Question 15

Give 8 risk factors for suicide

Answer 15

Whilst the evidence base is relatively weak, there are a number of factors shown to be associated with an increased risk of suicide
-male sex (hazard ratio (HR) approximately 2.0)
-history of deliberate self-harm (HR 1.7)
-alcohol or drug misuse (HR 1.6)
-history of mental illness: depression
schizophrenia: NICE estimates that 10% of people with schizophrenia will complete suicide
-history of chronic disease
-advancing age
-unemployment or social isolation/living alone
-being unmarried, divorced or widowed

Question 16

Give 5 risk factors for completing suicide at a future date if have already attempted suicide

Answer 16

If a patient has actually attempted suicide, there are a number of factors associated with an increased risk of completed suicide at a future date:
-efforts to avoid discovery
-planning
-leaving a written note
-final acts such as sorting out finances
-violent method

Question 17

Give 3 protective factors for suicide

Answer 17

There are, of course, factors which reduce the risk of a patient committing suicide. These include
family support
having children at home
religious belief

Question 18

SSRIs
-Which 2 are the preferred SSRIs
-Which SSRI is used post-MI
-Which SSRI is used in young people

Answer 18

Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment for the majority of patients with depression.
citalopram (although see below re: QT interval) and fluoxetine are currently the preferred SSRIs
sertraline is useful post myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants
SSRIs should be used with caution in children and adolescents. Fluoxetine is the drug of choice when an antidepressant is indicated

Question 19

Give 4 adverse effects of SSRIs

Answer 19

Adverse effects
-gastrointestinal symptoms are the most common side-effect
-there is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID
-patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI
-fluoxetine and paroxetine have a higher propensity for drug interactions

Question 20

Citalopram and the QT interval - who should this not be used in? what is the maximum daily dose?

Answer 20

Citalopram and the QT interval
-the Medicines and Healthcare products Regulatory Agency (MHRA) released a warning on the use of citalopram in 2011
it advised that citalopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in those with: congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval
-the maximum daily dose is now 40 mg for adults; 20 mg for patients older than 65 years; and 20 mg for those with hepatic impairment

Question 21

Give 5 drug interactions with sSRIS

Answer 21

Interactions
-NSAIDs: NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
-warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
-aspirin
-triptans - increased risk of serotonin syndrome
-monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome

Question 22

Following initiation when should patient be followed up? How are SSRIs stopped?

Answer 22

Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks. For patients under the age of 25 years or at increased risk of suicide should be reviewed after 1 week. If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse.

When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.

Question 23

Give 7 discontinuation symptoms of SSRIS

Answer 23

Discontinuation symptoms
-increased mood change
-restlessness
-difficulty sleeping
-unsteadiness
-sweating
-gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
-paraesthesia

Question 24

What are the risks of SSRIS in pregnancy?

Answer 24

SSRIs and pregnancy
- BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.
- Use during the first trimester gives a small increased risk of congenital heart defects
- Use during the third trimester can result in persistent pulmonary hypertension of the newborn
- Paroxetine has an increased risk of congenital malformations, particularly in the first trimester

Question 25

When are tricyclic antidepressants most commonly used?
-What are the 2 primary mechanisms?

Answer 25

Tricyclic antidepressants (TCAs) are used less commonly now for depression due to their side-effects and toxicity in overdose. They are however used widely in the treatment of neuropathic pain, where smaller doses are typically required.

The primary mechanism by which TCAs exert their antidepressant effects is through the inhibition of the reuptake of neurotransmitters
-Serotonin (5-HT): This neurotransmitter has a pivotal role in mood regulation. Inhibition of its reuptake leads to increased concentrations in the synaptic cleft, enhancing serotonergic neurotransmission.
-Noradrenaline (NA): Similar to 5-HT, blocking the reuptake of NA increases its synaptic cleft concentration, intensifying noradrenergic neurotransmission.

Question 26

What are 3 adverse effects of TCAs?

Answer 26

As well as 5-HT and NA, tricyclics interact with number of other receptors that contribute to their side-effect profile:

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

Question 27

Which tricyclic would you use for:
-neuropathic pain and prophylaxis of headache
-high risk of overdose
-which are most dangerous in overdose

Answer 27

Choice of tricyclic
-low-dose amitriptyline is commonly used in the management of neuropathic pain and the prophylaxis of headache (both tension and migraine)
-lofepramine has a lower incidence of toxicity in overdose
-amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose

Question 28

Which TCAs are more sedative vs less sedative

Answer 28

More sedative
Amitriptyline
Clomipramine
Dosulepin
Trazodone*

Less sedative
Imipramine
Lofepramine
Nortriptyline

Question 29

Which medications may trigger anxiety?

Answer 29

Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants and caffeine

Question 30

Give the four management steps of GAD?

Answer 30

NICE suggest a step-wise approach:
step 1: education about GAD + active monitoring
step 2: low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
step 3: high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information
step 4: highly specialist input e.g. Multi agency teams

Question 31

What drug treatment is indicated for GAD?

Answer 31

Drug treatment
-NICE suggest sertraline should be considered the first-line SSRI
-if sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI)
examples of SNRIs include duloxetine and venlafaxine
-If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin
-interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month

Question 32

Give the four management steps of panic disorder?

Answer 32

Again a stepwise approach:
step 1: recognition and diagnosis
step 2: treatment in primary care - see below
step 3: review and consideration of alternative treatments
step 4: review and referral to specialist mental health services
step 5: care in specialist mental health services

Treatment in primary care
-NICE recommend either cognitive behavioural therapy or drug treatment
-SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered

Question 33

What is acute stress disorder?

Answer 33

Acute stress disorder is defined as an acute stress reaction that occurs in the first 4 weeks after a person has been exposed to a traumatic event (threatened death, serious injury e.g. road traffic accident, sexual assault etc). This is in contrast to post-traumatic stress disorder (PTSD) which is diagnosed after 4 weeks.

Question 34

Give 5 features of acute stress disorder

Answer 34

Features include:
-intrusive thoughts e.g. flashbacks, nightmares
-dissociation e.g. ‘being in a daze’, time slowing
-negative mood
-avoidance
-arousal e.g. hypervigilance, sleep disturbance

Question 35

What is the management of acute stress disorder?

Answer 35

Management
trauma-focused cognitive-behavioural therapy (CBT) is usually used first-line
benzodiazepines
-sometimes used for acute symptoms e.g. agitation, sleep disturbance
-should only be used with caution due to addictive potential and concerns that they may be detrimental to adaptation

Question 36

What is PTSD?

Answer 36

Post-traumatic stress disorder (PTSD) can develop in people of any age following a traumatic event, for example, a major disaster or childhood sexual abuse. It encompasses what became known as ‘shell shock’ following the first world war. One of the DSM-IV diagnostic criteria is that symptoms have been present for more than one month.

Question 37

What four features may the patient describe in PTSD? What four features may others describe in PTSD?

Answer 37

Features
-re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
-avoidance: avoiding people, situations or circumstances resembling or associated with the event
-hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
-emotional numbing - lack of ability to experience feelings, feeling detached

from other people
-depression
-drug or alcohol misuse
-anger
-unexplained physical symptoms

Question 38

what is the management of PTSD 5?

Answer 38

Management
-following a traumatic event single-session interventions (often referred to as debriefing) are not recommended
-watchful waiting may be used for mild symptoms lasting less than 4 weeks
-military personnel have access to treatment provided by the armed forces
-trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases
-drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used then venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline should be tried. In severe cases, NICE recommends that risperidone may be used

Question 39

What is a agoraphobia?

Answer 39

Agoraphobia is primarily describes a fear of open spaces but also includes related aspects, e.g. the presence of crowds or the difficulty of escaping to a safe place

Question 40

What is OCD? What is an obsession? What is a compulsion?

Answer 40

Obsessive-compulsive disorder (OCD) is characterised by the presence of either obsessions or compulsions, but commonly both. The symptoms can cause significant functional impairment and/ or distress.

An obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind. Compulsions are repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one’s mind.

It is thought that 1 to 3% of the population have OCD.

Question 41

Give 4 risk factors for OCD

Answer 41

Risk factors
-family history
-age: peak onset is between 10-20 years
-pregnancy/postnatal period
-history of abuse, bullying, neglect

Question 42

Describe the management of OCD:
-Mild functional impairment
-Moderate functional impairment
-Severe functional impairment

Answer 42

Management
NICE recommend classifying impairment into mild, moderate or severe
they recommend the use of the Y-BOCS scale

an example of ‘severe’ OCD would be someone who spends > 3 hours a day on their obsessions/compulsions, has severe interference/distress and has very little control/resistance

If functional impairment is mild
low-intensity psychological treatments: cognitive behavioural therapy (CBT) including exposure and response prevention (ERP)
If this is insufficient or can’t engage in psychological therapy, then offer a choice of either a course of an SSRI or more intensive CBT (including ERP)

If moderate functional impairment
offer a choice of either a course of an SSRI (any SSRI for OCD but fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP)
consider clomipramine (as an alternative first-line drug treatment to an SSRI) if the person prefers clomipramine or has had a previous good response to it, or if an SSRI is contraindicated

If severe functional impairment
refer to the secondary care mental health team for assessment
whilst awaiting assessment - offer combined treatment with an SSRI and CBT (including ERP) or consider clomipramine as an alternative as above

Question 43

What is ERP?

Answer 43

ERP is a psychological method which involves exposing a patient to an anxiety provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping them engaging in their usual safety behaviour (e.g. washing their hands). This helps them confront their anxiety and the habituation leads to the eventual extinction of the response

Question 44

Describe treatment of OCD with SSRIS

Answer 44

f treatment with SSRI is effective then continue for at least 12 months to prevent relapse and allow time for improvement
compared to depression, the SSRI usually requires a higher dose and a longer duration of treatment (at least 12 weeks) for an initial response

Question 45

Anorexia nervosa
-who is most likely affected?

Answer 45

Anorexia nervosa is the most common cause of admissions to child and adolescent psychiatric wards.

Epidemiology
90% of patients are female
predominately affects teenage and young-adult females
prevalence of between 1:100 and 1:200

Question 46

What are the 3 DSM 5 criteria of anorexia nervosa?

Answer 46

Diagnosis is now based on the DSM 5 criteria. Note that BMI and amenorrhoea are no longer specifically mentioned:
1. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
2. Intense fear of gaining weight or becoming fat, even though underweight.
3. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

Question 47

What is the management of adults with AN? What is the management of children/young people with AN?

Answer 47

For adults with anorexia nervosa, NICE recommend we consider one of:
individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
specialist supportive clinical management (SSCM).

In children and young people, NICE recommend ‘anorexia focused family therapy’ as the first-line treatment. The second-line treatment is cognitive behavioural therapy.

The prognosis of patients with anorexia nervosa remains poor. Up to 10% of patients will eventually die because of the disorder.

Question 48

Give 4 features and 7 physiological abnormalities of AN?

Answer 48

Anorexia nervosa is associated with a number of characteristic clinical signs and physiological abnormalities which are summarised below

Features
-reduced body mass index
-bradycardia
-hypotension
-enlarged salivary glands

Physiological abnormalities
-hypokalaemia
-low FSH, LH, oestrogens and testosterone
-raised cortisol and growth hormone
-impaired glucose tolerance
-hypercholesterolaemia
-hypercarotinaemia
-low T3

Question 49

What are the 5 stages of grief reaction?

Answer 49

One of the most popular models of grief divides it into 5 stages.
-Denial: this may include a feeling of numbness and also pseudohallucinations of the deceased, both auditory and visual. Occasionally people may focus on physical objects that remind them of their loved one or even prepare meals for them
-Anger: this is commonly directed against other family members and medical professionals
-Bargaining
-Depression
-Acceptance

Question 50

What are the two features of abnormal grief reaction?

Answer 50

Abnormal, or atypical, grief reactions are more likely to occur in women and if the death is sudden and unexpected. Other risk factors include a problematic relationship before death or if the patient has not much social support.

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

Question 51

What is bipolar disorder? how many types are recognised?

Answer 51

Bipolar disorder is a chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression.

Epidemiology
typically develops in the late teen years
lifetime prevalence: 2%

Two types of bipolar disorder are recognised:
type I disorder: mania and depression (most common)
type II disorder: hypomania and depression

Question 52

What is the difference between mania vs hypomania?

Answer 52

What is mania/hypomania?
both terms relate to abnormally elevated mood or irritability
with mania, there is severe functional impairment or psychotic symptoms for 7 days or more
hypomania describes decreased or increased function for 4 days or more
from an exam point of view the key differentiation is psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) which suggest mania

Question 53

Give 5 management points of bipolar disorder

Answer 53

Management
-psychological interventions specifically designed for bipolar disorder may be helpful
-lithium remains the mood stabilizer of choice. An alternative is valproate
-management of mania/hypomania
consider stopping antidepressant if the patient takes one; antipsychotic therapy e.g. olanzapine or haloperidol
-management of depression
talking therapies (see above); fluoxetine is the antidepressant of choice
-address co-morbidities

there is a 2-3 times increased risk of diabetes, cardiovascular disease and COPD

Question 54

When should patients be referred for ?bipolar disorder

Answer 54

Primary care referral
if symptoms suggest hypomania then NICE recommend routine referral to the community mental health team (CMHT)
if there are features of mania or severe depression then an urgent referral to the CMHT should be made

Question 55

Describe mania vs hypomania

Answer 55

Mania
Lasts for at least 7 days - Causes severe functional impairment in social and work setting
May require hospitalization due to risk of harm to self or others
May present with psychotic symptoms

Hypomania
A lesser version of mania
Lasts for < 7 days, typically 3-4 days. Can be high functioning and does not impair functional capacity in social or work setting
Unlikely to require hospitalization
Does not exhibit any psychotic symptoms

Question 56

Describe mood, speech and thought and behavior during mania/hypomania episodes?

Answer 56

Mood
predominately elevated
irritable

Speech and thought
pressured
flight of ideas: characterised by rapid speech with frequent changes in topic based on associations, distractions or word play
poor attention

Behaviour
insomnia
loss of inhibitions: sexual promiscuity, overspending, risk-taking
increased appetite

Question 57

What are schneiders first rank symptoms of schizophrenia?

Answer 57

Schneider’s first rank symptoms may be divided into auditory hallucinations, thought disorders, passivity phenomena and delusional perceptions:

Auditory hallucinations of a specific type:
two or more voices discussing the patient in the third person
thought echo
voices commenting on the patient’s behaviour

Thought disorders
thought insertion
thought withdrawal
thought broadcasting

Passivity phenomena:
bodily sensations being controlled by external influence
actions/impulses/feelings - experiences which are imposed on the individual or influenced by others

Delusional perceptions
a two stage process) where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. ‘The traffic light is green therefore I am the King’.

Question 58

Give 4 other features of schizophrenia that do not come under schneiders first rank symptoms?

Answer 58

Other features of schizophrenia include
impaired insight

negative symptoms
incongruity/blunting of affect
anhedonia (inability to derive pleasure)
alogia (poverty of speech)
avolition (poor motivation)
social withdrawal

neologisms: made-up words

catatonia

Question 59

What is the strongest risk factor for developing a psychotic disorder?

Answer 59

The strongest risk factor for developing a psychotic disorder (including schizophrenia) is family history. Having a parent with schizophrenia leads to a relative risk (RR) of 7.5.

Risk of developing schizophrenia
monozygotic twin has schizophrenia = 50%
parent has schizophrenia = 10-15%
sibling has schizophrenia = 10%
no relatives with schizophrenia = 1%

Question 60

Give 4 other risk factors for developing psychotic disorder other than family history?

Answer 60

Other selected risk factors for psychotic disorders include:
-Black Caribbean ethnicity - RR 5.4
-Migration - RR 2.9
-Urban environment- RR 2.4
-Cannabis use - RR 1.4

Question 61

What are 3 key points in the management of schizophrenia?

Answer 61

NICE published guidelines on the management of schizophrenia in 2009.

Key points:
-oral atypical antipsychotics are first-line
-cognitive behavioural therapy should be offered to all patients
-close attention should be paid to cardiovascular risk-factor modification due to the high rates of cardiovascular disease in schizophrenic patients (linked to antipsychotic medication and high smoking rates)

Question 62

What is flight of ideas?

Answer 62

Flight of ideas, a feature of mania, is a thought disorder where there are leaps from one topic to another but with discernible links between them.

Question 62

What is word salad?

Answer 62

Word salad describes completely incoherent speech where real words are strung together into nonsense sentences.

Question 62

What is circumstantiality?

Answer 62

Circumstantiality is the inability to answer a question without giving excessive, unnecessary detail. However, this differs from tangentiality in that the person does eventually return to the original point.

Question 63

What is tangentiality?

Answer 63

Tangentiality refers to wandering from a topic without returning to it.

Question 64

What is a neologism?

Answer 64

Neologisms are new word formations, which might include the combining of two words.

Question 65

What are clang associations?

Answer 65

Clang associations are when ideas are related to each other only by the fact they sound similar or rhyme.

Question 66

What is echolalia?

Answer 66

Echolalia is the repetition of someone else’s speech, including the question that was asked.

Question 67

What is alogia?

Answer 67

alogia: little information conveyed by speech

Question 68

What is knights move thinking?

Answer 68

Knight’s move thinking is a severe type of loosening of associations, where there are unexpected and illogical leaps from one idea to another. It is a feature of schizophrenia.

Question 69

Give 5 risk factors assoc, with poor prognosis in schizophrenia?

Answer 69

Factors associated with poor prognosis
-strong family history
-gradual onset
-low IQ
-prodromal phase of social withdrawal
-lack of obvious precipitant

Question 70

Typical antipsychotics
-Give 2 examples
-What is the main mechanism?
-What are 2 adverse effects?

Answer 70

Typical antipsychotics:
Chlorpromazine
haloperidol

Mechanisms
Dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways

Adverse effects
Extrapyramidal side-effects and hyperprolactinaemia common

Question 71

Atypical antipsychotics:
-Give 3 examples
-What is the main mechanism?
-What are the adverse effects?

Answer 71

Atypical:
-Quetiapine
-Olanzapine
-Risperidone
-Clozapine

Mechanisms
-Variety of receptor (D3, D3, D4, 5-HT)\

Adverse effects
-extrapyradimal and hyperprolactinaemia side effects less common
-Metabolic effects

Question 72

Give 4 extra pyramidal side effects

Answer 72

Extrapyramidal side-effects (EPSEs)
-Parkinsonism
-acute dystonia
sustained muscle contraction (e.g. torticollis, oculogyric crisis)
may be managed with procyclidine
-akathisia (severe restlessness)
-tardive dyskinesia (late onset of -choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)

Question 73

What are two risks of antipsychotics in elderly>

Answer 73

The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:
increased risk of stroke
increased risk of venous thromboembolism

Question 74

Give 6 other side effects of antipsychotics

Answer 74

Other side-effects
-antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
sedation, weight gain

-raised prolactin
may result in galactorrhoea
due to inhibition of the dopaminergic tuberoinfundibular pathway

impaired glucose tolerance

neuroleptic malignant syndrome: pyrexia, muscle stiffness

reduced seizure threshold (greater with atypicals)

prolonged QT interval (particularly haloperidol)

Question 75

Give 3 adverse effects of atypical antipsychotics

Answer 75

Adverse effects of atypical antipsychotics
weight gain
clozapine is associated with agranulocytosis (see below)
hyperprolactinaemia

Question 76

What 6 things are monitored whilst taking antipsychotic medications?

Answer 76

Full blood count (FBC), urea and electrolytes (U&E), liver function tests (LFT)
-at the start of therapy
-annually
-clozapine requires much more frequent monitoring of FBC (initially weekly)

Lipids, weight
-at the start of therapy
-at 3 months
-annually

Fasting blood glucose, prolactin
-at the start of therapy
-at 6 months
-annually

Blood pressure
-baseline
-frequently during dose titration

Electrocardiogram
-baseline

Cardiovascular risk assessment
annually

Question 77

When is clozapine used? what are 5 adverse effects?

Answer 77

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

Adverse effects of clozapine
-agranulocytosis (1%), neutropaenia (3%)
-reduced seizure threshold - can induce seizures in up to 3% of patients
-constipation
-myocarditis: a baseline ECG should be taken before starting treatment
-hypersalivation

Dose adjustment of clozapine might be necessary if smoking is started or stopped during treatment.

Question 78

How do benzodiazepines work? what 5 purposes are they used for?

Answer 78

Benzodiazepines enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) by increasing the frequency of chloride channels. They therefore are used for a variety of purposes:
-sedation
-hypnotic
-anxiolytic
-anticonvulsant
-muscle relaxant

Question 79

How long should benzodiazepines be prescribed for? How should they be withdrawn?

Answer 79

Patients commonly develop a tolerance and dependence to benzodiazepines and care should therefore be exercised on prescribing these drugs. The Committee on Safety of Medicines advises that benzodiazepines are only prescribed for a short period of time (2-4 weeks).

The BNF gives advice on how to withdraw a benzodiazepine. The dose should be withdrawn in steps of about 1/8 (range 1/10 to 1/4) of the daily dose every fortnight. A suggested protocol for patients experiencing difficulty is given:
switch patients to the equivalent dose of diazepam
reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg
time needed for withdrawal can vary from 4 weeks to a year or more

Question 80

What can happen if patients withdraw too quickly from benzodiazepines?

Answer 80

If patients withdraw too quickly from benzodiazepines they may experience benzodiazepine withdrawal syndrome, a condition very similar to alcohol withdrawal syndrome. This may occur up to 3 weeks after stopping a long-acting drug. Features include:
-insomnia
-irritability
-anxiety
-tremor
-loss of appetite
-tinnitus
-perspiration
-perceptual disturbances
-seizures

Question 81

How do barbiturates vs benzodiazepines affect GABA

Answer 81

GABAA drugs
benzodiazipines increase the frequency of chloride channels
barbiturates increase the duration of chloride channel opening

Frequently Bend - During Barbeque

…or…

Barbidurates increase duration & Frendodiazepines increase frequency

Question 82

What is lithium? what is the therapeutic range? and what is the mechanism of action?

Answer 82

Lithium is mood stabilising drug used most commonly prophylactically in bipolar disorder but also as an adjunct in refractory depression. It has a very narrow therapeutic range (0.4-1.0 mmol/L) and a long plasma half-life being excreted primarily by the kidneys.

Mechanism of action - not fully understood, two theories:
interferes with inositol triphosphate formation
interferes with cAMP formation

Question 83

Give 9 adverse effects of lithium

Answer 83

Adverse effects
-nausea/vomiting, diarrhoea
-fine tremor
-nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
-thyroid enlargement, may lead to -hypothyroidism
-ECG: T wave flattening/inversion
-weight gain
-idiopathic intracranial hypertension
-leucocytosis
-hyperparathyroidism and resultant hypercalcaemia

Question 84

Lithium level monitoring:
-When should lithium levels be checked?
-How often should lithium levels be checked when starting, once established and after a change in dose?
-What other bloods need to be taken and how often?
-what should patients on lithium be issued with?

Answer 84

Monitoring of patients on lithium therapy
inadequate monitoring of patients taking lithium is common - NICE and the National Patient Safety Agency (NPSA) have issued guidance to try and address this. As a result it is often an exam hot topic
-when checking lithium levels, the sample should be taken 12 hours post-dose
-after starting lithium levels should be performed weekly and after each dose change until concentrations are stable
-once established, lithium blood level should ‘normally’ be checked every 3 months
-after a change in dose, lithium levels should be taken a week later and weekly until the levels are stable.
-thyroid and renal function should be checked every 6 months
-patients should be issued with an information booklet, alert card and record book

Question 85

How does mirtazapine work? what are the main adverse effects? when is this taken?

Answer 85

Mirtazapine is an antidepressant that works by blocking alpha2-adrenergic receptors, which increases the release of neurotransmitters.

Mirtazapine has fewer side effects and interactions than many other antidepressants and so is useful in older people who may be affected more or be taking other medications. Two side effects of mirtazapine, sedation and an increased appetite, can be beneficial in older people that are suffering from insomnia and poor appetite.

It is generally taken in the evening as it can be sedative.

Question 86

Describe the mechanism of alcohol withdrawal

Answer 86

Mechanism
-chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
-alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)

Question 87

What are 3 features of alcohol withdrawal?

Answer 87

Features
-symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
-peak incidence of seizures at 36 hours
-peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia

Question 88

What is used to manage alcohol withdrawal?

Answer 88

Management
-patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised
-first-line: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol
-carbamazepine also effective in treatment of alcohol withdrawal
-phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures

Question 89

What is aphonia?

Answer 89

Aphonia describes the inability to speak. Causes include:
recurrent laryngeal nerve palsy (e.g. Post-thyroidectomy)
psychogenic

Question 90

What is charles-bonnet? what are 5 risk factors?

Answer 90

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

Risk factors include:
-Advanced age
-Peripheral visual impairment
-Social isolation
-Sensory deprivation
-Early cognitive impairment

Question 91

Who is charles-bonnet most commonly seen in? What does this cause? Is this disturbing?

Answer 91

CBS is equally distributed between sexes and does not show any familial predisposition. The most common ophthalmological conditions associated with this syndrome are age-related macular degeneration, followed by glaucoma and cataract.

Well-formed complex visual hallucinations are thought to occur in 10-30 per cent of individuals with severe visual impairment. Prevalence of CBS in visually impaired people is thought to be between 11 and 15 per cent.

Around a third find the hallucinations themselves an unpleasant or disturbing experience. In a large study published in the British Journal of Ophthalmology, 88% had CBS for 2 years or more, resolving in only 25% at 9 years (thus it is not generally a transient experience).

Question 92

What is cotard syndrome?

Answer 92

Cotard syndrome is a rare mental disorder where the affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent. This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary.

Cotard syndrome is associated with severe depression and psychotic disorders.

Question 93

What is De Clerambault’s syndrome?

Answer 93

De Clerambault’s syndrome, also known as erotomania, is a form of paranoid delusion with an amorous quality. The patient, often a single woman, believes that a famous person is in love with her.

Question 94

What is delusional parasitosis?

Answer 94

Delusional parasitosis is a relatively rare condition where a patient has a fixed, false belief (delusion) that they are infested by ‘bugs’ e.g. worms, parasites, mites, bacteria, fungus. This may occur in conjunction with other psychiatric conditions or may present by itself, with patients often otherwise quite functional despite the delusion.

Question 95

What is othellos syndrome?

Answer 95

Othello’s syndrome is pathological jealousy where a person is convinced their partner is cheating on them without any real proof. This is accompanied by socially unacceptable behaviour linked to these claims.

Question 96

What are personaliy disorders and what are the three clusters?

Answer 96

Personality disorders may be defined as a series of maladaptive personality traits that interfere with normal function in life. It is thought that around 1 in 20 people have a personality disorder. They are typically categorised as belonging to one of three clusters:

Cluster A: ‘Odd or Eccentric’
Paranoid
Schizoid
Schizotypal

Cluster B: ‘Dramatic, Emotional, or Erratic’
Antisocial
Borderline (Emotionally Unstable)
Histrionic
Narcissistic

Cluster C: ‘Anxious and Fearful’
Obsessive-Compulsive
Avoidant
Dependent

Question 97

What are features of paranoid personality disorder?

Answer 97

Paranoid
-Hypersensitivity and an unforgiving attitude when insulted
-Unwarranted tendency to questions the loyalty of friends
-Reluctance to confide in others
-Preoccupation with conspirational beliefs and hidden meaning
-Unwarranted tendency to perceive attacks on their character

Question 98

What are features of schizoid personality disorder?

Answer 98

Schizoid
-Indifference to praise and criticism
-Preference for solitary activities
-Lack of interest in sexual interactions
-Lack of desire for companionship
-Emotional coldness
-Few interests
-Few friends or confidants other than family

Question 99

What are features of schizotypal personality disorder?

Answer 99

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

Question 100

What are features of antisocial personality disorder?

Answer 100

Antisocial
-Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest;
-More common in men;
-Deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
-Impulsiveness or failure to plan ahead;
Irritability and aggressiveness, as indicated by repeated physical fights or assaults;
-Reckless disregard for the safety of self or others;
-Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations;
-Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

Question 101

What are features of EUPD?

Answer 101

Borderline - also known as Emotionally Unstable
-Efforts to avoid real or imagined abandonment
-Unstable interpersonal relationships which alternate between idealization and devaluation
-Unstable self image
-Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse)
-Recurrent suicidal behaviour
-Affective instability
-Chronic feelings of emptiness
-Difficulty controlling temper
-Quasi psychotic thoughts

Question 102

What are features of histrionic personality disordeR?

Answer 102

Histrionic
-Inappropriate sexual seductiveness
-Need to be the centre of attention
-Rapidly shifting and shallow expression of emotions
-Suggestibility
-Physical appearance used for attention seeking purposes
-Impressionistic speech lacking detail
-Self dramatization
-Relationships considered to be more intimate than they are

Question 103

What are features of narcissistic personality disorder?

Answer 103

Narcissistic
-Grandiose sense of self importance
-Preoccupation with fantasies of unlimited success, power, or beauty
-Sense of entitlement
-Taking advantage of others to achieve own needs
-Lack of empathy
-Excessive need for admiration
-Chronic envy
-Arrogant and haughty attitude

Question 104

What are features of obsessive-compulsive personality disorder?

Answer 104

Obsessive-compulsive
-Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone
-Demonstrates perfectionism that hampers with completing tasks
-Is extremely dedicated to work and efficiency to the elimination of spare time activities
-Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values
-Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning
-Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things
-Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness

Question 105

What are features of avoidant personality disorder?

Answer 105

Avoidant
-Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection.
-Unwillingness to be involved unless certain of being liked
-Preoccupied with ideas that they are being criticised or rejected in social situations
-Restraint in intimate relationships due to the fear of being ridiculed
-Reluctance to take personal risks due to fears of embarrassment
-Views self as inept and inferior to others
-Social isolation accompanied by a craving for social contact

Question 106

What are features of dependant personality disordeR?

Answer 106

Dependent
-Difficulty making everyday decisions without excessive reassurance from others
-Need for others to assume responsibility for major areas of their life
-Difficulty in expressing disagreement with others due to fears of losing support
-Lack of initiative
-Unrealistic fears of being left to care for themselves
-Urgent search for another relationship as a source of care and support when a close relationship ends
-Extensive efforts to obtain support from others
-Unrealistic feelings that they cannot care for themselves

Question 107

Give 4 features of post-concussion syndrome?

Answer 107

Post-concussion syndrome is seen after even minor head trauma

Typical features include
headache
fatigue
anxiety/depression
dizziness

Question 108

What is SAD and how is this treated?

Answer 108

Seasonal affective disorder (SAD) describes depression which occurs predominately around the winter months. SAD should be treated the same way as depression, therefore as per the NICE guidelines for mild depression, you would begin with psychological therapies and follow up with the patient in 2 weeks to ensure that there has been no deterioration. Following this an SSRI can be given if needed. In seasonal affective disorder, you should not give the patient sleeping tablets as this can make the symptoms worse. Finally, the evidence for light therapy is limited and as such it is not routinely recommended.

Question 109

What is sleep paralysis? what are the features? what is the management?

Answer 109

Sleep paralysis is a common condition characterized by transient paralysis of skeletal muscles which occurs when awakening from sleep or less often while falling asleep. It is thought to be related to the paralysis that occurs as a natural part of REM (rapid eye movement) sleep. Sleep paralysis is recognised in a wide variety of cultures

Features
paralysis - this occurs after waking up or shortly before falling asleep
hallucinations - images or speaking that appear during the paralysis

Management
if troublesome clonazepam may be used

Question 110

What is somatisation disorder?

Answer 110

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

Question 111

What is illness anxiety disorder?

Answer 111

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

Question 112

What is conversion disorder?

Answer 112

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

Question 113

What is dissociative disorder?

Answer 113

Dissociative disorder
dissociation is a process of ‘separating off’ certain memories from normal consciousness
in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder

Question 114

What is factitious disorder? what is malingering?

Answer 114

Factitious disorder
also known as Munchausen’s syndrome
the intentional production of physical or psychological symptoms

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

Question 115

What are Z drugs? What are the three groups? what is an adverse effect in the elderly?

Answer 115

Z drugs have similar effects to benzodiazepines but are different structurally. They act on the α2-subunit of the GABA receptor.

They can be divided into 3 groups:
Imidazopyridines: e.g. zolpidem
Cyclopyrrolones: e.g. zopiclone
Pyrazolopyrimidines: e.g. zaleplon

Adverse effects
similar to benzodiazepines
increase the risk of falls in the elderly

Question 116

What is section 2 of the MHA?

Answer 116

Section 2
admission for assessment for up to 28 days, not renewable
an Approved Mental Health Professional (AMHP) or rarely the nearest relative (NR) makes the application on the recommendation of 2 doctors
one of the doctors should be ‘approved’ under Section 12(2) of the Mental Health Act (usually a consultant psychiatrist)
treatment can be given against a patient’s wishes

Question 117

What is section 3 of the MHA?

Answer 117

Section 3
admission for treatment for up to 6 months, can be renewed
AMHP along with 2 doctors, both of which must have seen the patient within the past 24 hours
treatment can be given against a patient’s wishes

Question 118

What is section 4 of the mental health act?

Answer 118

Section 4
72 hour assessment order
used as an emergency, when a section 2 would involve an unacceptable delay
a GP and an AMHP or NR
often changed to a section 2 upon arrival at hospital

Question 119

What is section 5(2) and section 5(4) of the MHA?

Answer 119

Section 5(2)
a patient who is a voluntary patient in hospital can be legally detained by a doctor for 72 hours

Section 5(4)
similar to section 5(2), allows a nurse to detain a patient who is voluntarily in hospital for 6 hours

Question 120

What is section 17a of the MHA?

Answer 120

Section 17a
Supervised Community Treatment (Community Treatment Order)
can be used to recall a patient to hospital for treatment if they do not comply with conditions of the order in the community, such as complying with medication

Question 121

What is section 135 and 136 of the MHA?

Answer 121

Section 135
a court order can be obtained to allow the police to break into a property to remove a person to a Place of Safety

Section 136
someone found in a public place who appears to have a mental disorder can be taken by the police to a Place of Safety
can only be used for up to 24 hours, whilst a Mental Health Act assessment is arranged