Psychiatry Flashcards

Question

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

Answer 1

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.

Answer 2

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

Answer 3

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

Answer 4

More sedative Amitriptyline Clomipramine Dosulepin Trazodone* Less sedative Imipramine Lofepramine Nortriptyline

Answer 5

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

Answer 6

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

Answer 7

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

Answer 8

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

Answer 9

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.

Answer 10

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

Answer 11

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

Answer 12

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.

Answer 13

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

Answer 14

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

Answer 15

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

Answer 16

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.

Answer 17

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

Answer 18

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

Answer 19

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

Answer 20

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

Answer 21

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

Answer 22

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.

Answer 23

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.

Answer 24

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

Answer 25

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

Answer 26

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

Answer 27

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

Answer 28

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

Answer 29

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

Answer 30

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

Answer 31

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

Answer 32

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

Answer 33

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'.

Answer 34

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

Answer 35

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%

Answer 36

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

Answer 37

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)

Answer 38

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.

Answer 39

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

Answer 40

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.

Answer 41

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

Answer 42

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

Answer 43

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

Answer 44

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

Answer 45

alogia: little information conveyed by speech

Answer 46

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.

Answer 47

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

Answer 48

Typical antipsychotics: Chlorpromazine haloperidol Mechanisms Dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways Adverse effects Extrapyramidal side-effects and hyperprolactinaemia common

Answer 49

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

Answer 50

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)

Answer 51

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

Answer 52

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)

Answer 53

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

Answer 54

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

Answer 55

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.

Answer 56

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

Answer 57

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

Answer 58

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

Answer 59

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

Answer 60

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

Answer 61

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

Answer 62

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

Answer 63

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.

Answer 64

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)

Answer 65

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

Answer 66

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

Answer 67

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

Answer 68

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

Answer 69

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).

Answer 70

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.

Answer 71

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.

Answer 72

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.

Answer 73

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.

Answer 74

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

Answer 75

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

Answer 76

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

Answer 77

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

Answer 78

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

Answer 79

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

Answer 80

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

Answer 81

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

Answer 82

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

Answer 83

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

Answer 84

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

Answer 85

Post-concussion syndrome is seen after even minor head trauma Typical features include headache fatigue anxiety/depression dizziness

Answer 86

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.

Answer 87

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

Answer 88

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

Answer 89

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

Answer 90

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

Answer 91

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

Answer 92

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

Answer 93

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

Answer 94

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

Answer 95

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

Answer 96

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

Answer 97

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

Answer 98

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

Answer 99

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