Psychiatry

Question 1

Name 4 anxiety/ stress-related disorders

Answer 1

Panic disorder
Phobias
Generalised anxiety disorder (GAD)
Post-traumatic stress disorder (PTSD)
Derealisation syndrome

Question 2

Define panic disorder

Answer 2

Recurrent unpredictable episodes of severe acute anxiety, which are not restricted to particular stimuli or situations.

Question 3

Clinical features of panic attacks

Answer 3

Crescendo of anxiety –> exit from situation.

Somatic symptoms (e.g. palpitations, sweating, chest pain, dizziness, chills, hot flushes).

Secondary fear of dying/ losing control.

Question 4

Define Generalised Anxiety Disorder (GAD)

Answer 4

Excessive worry/ feelings of apprehension around every events/ problems –> significant distress/ functional impairment

Question 5

What tool is commonly used to help establish the severity of GAD?

Answer 5

GAD-7

Question 6

Clinical features of GAD

Answer 6

Subjective experience of nervousness.

Difficulty maintaining concentration.

Muscular tension or motor restlessness.

Sympathetic autonomic over-activity (sweating, palpitations, tachycardia).

Irritability.

Sleep disturbance.

Question 7

Define Obsessive Compulsive Disorder (OCD)

Answer 7

Anxiety disorder characterised by the presence of obsessions and compulsions which distress or interfere with the person’s social or individual functioning.

Patients are able to recognise symptoms as excessive/ unreasonable.

Question 8

Define obsession

Answer 8

Idea/ image/ impulse which is recognised by the patient as their own but is experienced as repetitive/ intrusive/ distressing.

May be relieved by compulsions.

Question 9

Define compulsion

Answer 9

Behaviour/ action recognised by patient as unnecessary + purposeless but patient is unable to resist performing, often to avoid the occurrence of an adverse event.

Question 10

Name some common obsessions/ compulsions

Answer 10

Checking
Washing
Contamination
Doubting
Bodily fears
Counting
Insistence on symmetry
Aggressive thoughts

Question 11

Define Acute Stress Reaction

Answer 11

Transient disorder (hour/ days) that occurs as an immediate response to an exceptional stress (assault/ rape/ fire).

Question 12

Clinical presentation of an acute stress reaction

Answer 12

Initial state of daze followed by depression/ anxiety/ anger/ despair.

Symptoms usually resolve within a few hours of stressor removal.

Question 13

Define PTSD

Answer 13

severe psychological disturbance following a traumatic event

Characterised by involuntary re-experiencing of the event with symptoms of hyperarousal/ avoidance/ emotional numbing

Question 14

Clinical presentation of PTSD

Answer 14

HARD:

Hyperarousal - persistently heightened perception of current threat

Avoidance of situation/ activities

Re-experiencing

Distress

Question 15

Management of PTSD

Answer 15

Psychological therapy: trauma-focused CBT/ EMDR = first-line

Pharmacological: SSRI (e.g. sertraline)/ venlafaxine

Question 16

Define depersonalisation syndrome

Answer 16

persistent/ recurrent episodes of distressing feeling of unreality and detachment

Question 17

Depersonalisation vs. derealisation

Answer 17

Depersonalisation = unreality/ detachment from person’s own body/ thoughts/ feelings/ behaviour

Derealisation = unreality/ detachment from the outside world

Question 18

Name some common phobias

Answer 18

Agoraphobia - crowds, public places, leaving home

Social phobia - associated w/ low self-esteem and fear of criticism

Question 19

Define phobia

Answer 19

abnormal state of anxiety evoke only/ predominantly by a specific external situation/ object which is not currently dangerous

key feature = avoidance of that situation

Question 20

Principles of management of anxiety disorders

Answer 20

Psychological therapies address the problem

Medications reduce the intensity of state anxiety to better enable the person to engage with psychology

Question 21

Management of anxiety disorders

Answer 21

Social: psychoeducation, sleep hygiene, self-guided CBT, relaxation techniques

Psychological: CBT - unlearn maladaptive patterns of thought/ behaviour perpetuating symptoms

Pharmacological: SSRI (e.g. escitalopram/ sertraline)/ SNRI (e.g. duloxetine/ venlafaxine)

Question 22

Define anorexia nervosa

Answer 22

A psychiatric condition most common in young women, characterised by marked distortion of body image, pathological desire to be thinner, and self-induced weight loss by a variety of methods.

Significant mortality (10-15% if untreated).

Question 23

Clinical presentation of anorexia nervosa

Answer 23

Weight loss (15% below expected/ BMI <17.5) - avoidance of fattening foods, vomiting, purging, excessive exercise, use of laxatives/ appetite suppressants

Amenorrhoea

Lanugo hair (fine, soft hair across most of the body)

Hypotension

Hypothermia

Mood changes (incl. anxiety and depression)

Question 24

Management of anorexia nervosa

Answer 24

Fluoxetine (helps with obsessional ideas regarding food)

Family therapy/ individual therapy (e.g. CBT)

Question 25

Admission to hospital for anorexia nervosa

Answer 25

Rapid/ excessive weight loss not responding to out-patient Tx

Severe electrolyte imbalance (hyponatraemia, hypocalcaemia, hypophosphatemia, hypomagnesaemia)

Serious physiological complication (e.g. temp <36)

Cardiac complications (arrhythmias, cardiomyopathy)

Marked change in mental state due to severe malnutrition

Psychosis/ significant risk of suicide

Question 26

Blood results in restrictive eating disordedrs

Answer 26

Anaemia (low Hb)
Leucopenia (low WCC)
Thrombocytopenia (low platelets)
Hypokalaemia (low potassium)

Question 27

What is refeeding syndrome?

Answer 27

When someone with an extended severe nutritional deficit resumes eating.

RFs: lower BMI, longer period of malnutrition.

Prolonged starvation –> intracellular potassium/ phosphate/ magnesium depleted so move to blood.

Refeeding –> these electrolytes are moved out of the blood by various mechanisms which simultaneously cause sodium to move into the blood –> hypomagnesaemia (low serum magnesium), hypokalaemia, hypophosphatemia + FLUID OVERLOAD –> risk of arrhythmia + HF

Question 28

Management of refeeding syndrome

Answer 28

Slowly reintroducing food with limited calories

Magnesium, potassium, phosphate and glucose monitoring

Fluid balance monitoring

ECG monitoring in severe cases

Supplementation with electrolytes and vitamins, particularly B vitamins and thiamine

Question 29

Define bulimia nervosa

Answer 29

Recurrent episodes of binge eating with compensatory behaviours and overvalued ideas about ‘ideal’ body shape and weight, often with past Hx of anorexia nervosa + normal body weight

Question 30

Clinical features of bulimia nervosa

Answer 30

Erosion of teeth

Swollen salivary glands

Mouth ulcers

gastro-oesophageal reflux

Russell’s sign - calluses on knuckle where they have been scraped across the teeth

Alkalosis - from repeated vomiting of hydrochloric acid from the stomach

Question 31

Screening tool for bulimia nervosa

Answer 31

SCOFF: 2+ = more detailed Hx requried

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’re too thin?
Would you say that FOOD dominates your life?

Question 32

Management of bulimia nervosa

Answer 32

High-dose SSRi e.g. fluoxetine

Psychotherapy - CBT = best-evidence (or IPT)