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MRCP Part 1 > Psychiatry 2 > Flashcards

Psychiatry 2 Flashcards

1
Q

A 64yo woman presents as she is feeling down and sleeping poorly. After speaking to the patient and using a validated symptom measure, you decide she has moderate depression. She has a past history of ischaemic heart disease and currently takes aspirin, ramipril and simvastatin. What medication change should you advise?

A

Start Sertraline and Lansoprazole

SSRI + NSAID = GI bleeding risk
-> Give a PPI

  • Sertraline = 1st choice SSRI in patients with a history of cardiovascular disease.
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2
Q

There is an increased incidence of GI bleeding when Aspirin/NSAIDS are combined with SSRIs. What should you offer patients on both of these drugs?

A

Offer a PPI, such as Lansoprazole.

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3
Q

SSRIs are considered 1st-line treatment for the majority of patients with depression.
Which 2 SSRIs are currently the ‘preferred’ SSRIs?

A
  • Citalopram (although beware QT interval prolongation)

- Fluoxetine

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4
Q

Which SSRI is preferable in a patient who is post-MI?

A

Sertraline

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5
Q

SSRIs should be used with caution in children and adolescents. Which SSRIs is the drug of choice when an antidepressant is indicated in this age group?

A

Fluoxetine

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6
Q

What are the adverse effects of SSRIs?

A
  • GI symptoms are the most common side-effect
  • Increased risk of GI bleed in patients taking SSRIs -> PPI should be prescribed if a patient is also taking an NSAID.
  • Patients should be counselled to be vigilant for increased anxiety and agitation after starting an SSRI
  • Fluoxetine and Paroxetine have a higher propensity for drug interactions.
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7
Q

Citalopram and Escitaloprim are associated with dose-dependent QT interval prolongation. Which patients should these medications NOT be used in?

A

Patients with:

  • Congenital Long QT syndrome
  • known pre-existing QT interval prolongation
  • Do not use in combination with other medications which prolong the QT interval.
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8
Q

SSRIs interact with a number of different medications. List these.

A
  • NSAIDs / Aspirin : NICE guidelines advise ‘do not normally offer SSRIs’, but if given, co-prescribe a PPI.
  • Warfarin / Heparin: NICE guidelines recommend avoiding SSRIs and considering Mirtazapine
  • Triptans: increased risk of Serotonin Syndrome
  • Monoamine Oxidase Inhibitors (MAOIs): increased risk of Serotonin Syndrome.
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9
Q

What follow up / advice should you carry out when starting a patient on an SSRI?

A
  • After starting antidepressant therapy, patients should normally be reviewed by a doctor after 2 weeks.
  • For patients under 30y, or at increased risk of suicide, they should be reviewed after a week.
  • If a patient makes a good response to antidepressant therapy, they should continue on treatment for at least 6 months after remission. This reduces the risk of relapse.
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10
Q

What advice should you give to a patient who is stopping SSRI treatment?

A
  • 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.
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11
Q

List some discontinuation symptoms which might be seen when a patient stops taking an SSRI.

A
  • Increased mood change
  • Restlessness
  • Difficulty sleeping
  • Unsteadiness
  • Sweating
  • GI symptoms: pain, cramping, diarrhoea, vomiting
  • Paraesthesia
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12
Q

What is the guidance for SSRIs in pregnancy?

A

BNF says: ‘weigh up benefits and risk when deciding whether to use in pregnancy’.

  • Use during the 1st trimester gives a small increased risk of congenital heart defects
  • Use during the 3rd trimester can result in Persistent pulmonary hypertension of the newborn
  • Paroxetine has an increased risk of congenital malformations, particularly in the 1st trimester.
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13
Q

Which scale can be used to screen for depression in the postpartum phase?

A

Edinburgh Postnatal Depression Scale

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14
Q

What does the Edinburgh Postnatal Depression Scale consist of?

A
  • 10-item questionnaire, with a maximum score of 30;
  • Indicates how the mother has felt over the previous week;
  • Score > 13 indicates a ‘depressive illness of varying severity’.
  • Sensitivity and Specificity > 90%;
  • Includes a question about self harm.
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15
Q

What percentage of women experience ‘Baby blues’ postnatally and when is this seen?

A
  • Seen in around 60 - 70% of women

- Typically seen 3 - 7 days following birth and is more common in Primips

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16
Q

How might a mother behave if they are suffering from the ‘baby-blues’ postnatally?

A

Mothers are characteristically anxious, tearful and irritable.

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17
Q

What is the treatment for ‘Baby-Blues’?

A
  • Reassurance and support

- The Health Visitor has a key role

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18
Q

What percentage of women are affected by post-natal depression?
When does post-natal depression usually occur?

A
  • Around 10% of women are affected by post-natal depression

- Most cases start within a month and typically peak at around 3 months

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19
Q

What are the features of post-natal depression?

A

Features are similar to depression seen in other circumstances.

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20
Q

What is the treatment for Post-Natal depression?

A
  • As with baby blues, reassurance and support are important
  • Cognitive Behavioural therapy may be beneficial.
    Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe. These are both secreted in breast milk, but it is not thought to be harmful to the infant.
    -> Fluoxetine is best avoided due to a long half life.
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21
Q

What percentage of women are affected by Puerperal psychosis?

A

Approximately 0.2% of women

22
Q

When does Puerperal psychosis usually manifest?

A

Onset usually within the first 2-3 weeks following birth

23
Q

What are the features of Puerperal psychosis?

A
  • Severe mood swings (similar to bipolar disorder)

- Disordered perception (eg. auditory hallucinations)

24
Q

What is the treatment for Puerperal psychosis?

A
  • Admission to hospital is usually required

- There is around a 20% risk of recurrence following future pregnancies.

25
Q

A 35yo man with a history of schizophrenia is transferred to the emergency department due to an oculogyric crisis. What is the most appropriate treatment?

A

Procyclidine

26
Q

Which class of drug have the MHRA warned may be associated with an increased risk of venous thromboembolism in elderly patients?

A

Atypical Antipsychotics

Antipsychotics in the elderly: increased risk of stroke and VTE.

27
Q

Olazapine is known to block D2 dopamine receptors. Which other type of receptor does it mainly act on?

A

Serotonin Receptors

Olanzapine, like other atypical antipsychotics, is known to block Serotonin Receptors (especially the 5-HT2 subtype) as well as D2 receptors.

28
Q

An 84yo female attends clinic with her daughter. She has a PMHx of HTN, fractured NOF 6 months ago. Her daughter reports that over the last few months, she has become highly occupied with her BP and diet, measuring her BP several times per day. Her daughter feels that her concerns over her physical health are affecting her mood. She becomes easily agitated and snaps at her daughter. The patient denies any problems with her memory or mood but does report difficulty in getting to sleep.
What is the most likely diagnosis?

A

Depression

Elderly patients with depression are less likely to complain of low mood, and instead may present with health anxiety, agitation and sleep disturbance.

Her recent hip fracture and subsequent hospitalisation may have acted as a trigger of low mood.

29
Q

Why is depression in elderly patients more challenging to diagnose?

A
  • Patients often present with health anxiety, poor sleep and agitation
  • Less commonly present with low mood or classical features of depression.
30
Q

List 3 features of depression in older people.

A
  • Physical complaints (eg. hypochondriasis)
  • Agitation
  • Insomnia
31
Q

How should you manage depression in older people?

A

SSRIs are first line
Note: The adverse side-effect profile of tricyclic antidepressants is more of an issue in the elderly, hence TCAs are not first line.

32
Q

A 24yo male is admitted to the Emergency Department complaining of severe abdominal pain.
On examination, he is shivery and rolling around the trolly.
He has previously been investigated for abdominal pain and no cause has been found.
He states that, unless he is given morphine for the pain, he will kill himself.
This is an example of which disorder?

A

Malingering.

Lying or exaggerating for financial gain is malingering.
eg. someone who fakes whiplash after a road traffic accident for an insurance patient.

33
Q

Victoria has recently been diagnosed with agoraphobia and the psychiatrist plans to start medical treatment. Which is the first line medications used for agoraphobia?

A

Sertraline

Agoraphobia is usually managed with Sertraline.

34
Q

What is Agoraphobia and what is the 1st line treatment?

A

Agoraphobia: 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.

Treatment: Sertraline

35
Q

A young couple see you in GP land. The wife explains how her partner has been acting out of character, specifically, checking on their daughter subtly throughout the day and night. On average, he would check 10-20 times. When asked, he explains that last month he nearly lost his daughter in the park where it was a scary ordeal and he repeatedly relives what happened in his mind. The husband says he does not go to the park any more, feels anxious and has difficulty sleeping.
There is no past medical or psychiatric history of note.
What is the most likely diagnosis?

A

Post-Traumatic Stress Disorder

Common features of PTSD:

  • re-experiencing eg. flashbacks, nightmares
  • Avoidance eg. avoiding people or situations
  • Hyperarousal eg. hyper vigilance, sleep problems
36
Q

List 4 common features of PTSD.

A
  1. Re-experiencing: eg. flashbacks, nightmares
  2. Avoidance eg. avoiding people or situations
  3. Hyperarousal eg. hyper vigilance, sleep problems
  4. Emotional numbing: lack of ability to experience feelings / feeling detached
37
Q

To be diagnosed with PTSD, how long do symptoms need to persist for?

A

Symptoms must persist for over a month.

38
Q

When might PTSD develop?

A
  • Can develop in people of any age following a traumatic event
    eg. major disaster, childhood sexual abuse
  • One of the DSM-IV diagnostic criteria is that symptoms have been present for more than 1 month.
39
Q

What features might a partner / relative notice in someone who is experiencing PTSD?

A
  • Depression
  • Drug / alcohol misuse
  • Anger
  • Unexplained physical symptoms
40
Q

What is the management of PTSD?

A
  • Watchful waiting for mild symptoms lasting less than 4 weeks
  • Military personnel have access to treatment provided by the armed forces
  • Trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases
  • Drug treatments should not be used as a first-line treatment for adits.
  • If drug treatment is used, then Venlafaxine or a SSRI (eg. Sertraline) should be tried.
  • In severe cases, nice recommends Risperidone be used.
41
Q

A 39 yo man comes for review. 6 months ago he was started on Paroxetine for depression. Around 5 days ago, he stopped taking the medication as he felt that it was having no benefit. PMHx of Asthma.
For the past 2 days he has experienced increased anxiety, sweating, headache, and the feeling of a needle-like sensation in his head.
During the consultation he is pacing around the room.
What is the most likely explanation for his symptoms?

A

SSRI discontinuation syndrome.

* Paroxetine has a higher incidence of discontinuation symptoms than other SSRIs.

42
Q

What is the maximum daily dose of citalopram for:

i) Adults?
ii) Patients over 65 years old?
iii) those with hepatic impairment?

A

Maximum daily dose of Citalopram for:

i) Adults: 40mh
ii) Over 65s: 20mg
iii) Hepatic impairment: 20mg

43
Q

A patient reports feeling unwell after suddenly stopping Paroxetine. Which one of the following symptoms is most consistent with SSRI discontinuation syndrome?

  • Postural hypotension
  • Diarrhoea
  • Myoclonic jerks
  • Hallucinations
  • Seizures
A

Diarrhoea

GI side-effects such as diarrhoea are seen in SSRI discontinuation syndrome.

SSRI discontinuation syndrome can present with a wide variety of symptoms including diarrhoea, vomiting and abdominal pain.

44
Q

A 38yo patient presents with nausea, headaches and palpitations.
He has had multiple previous admissions with such symptoms over the past 2 years, and each time no organic cause was found. What kind of disorder is this likely to represent?

A

Somatisation Disorder:

  • multiple physical SYMPTOMs present for at least 2 years
  • Patient refuses to accept reassurance or negative test results

Remember:
Somatisation = Symptoms
HypoChondria = Cancer

45
Q

A 25yo man demands a CT scan of his abdomen in clinic. He says it is ‘obvious’’ he has cancer despite previous negative investigations. What kind of disorder is this likely to represent?

A

Hypochondrial disorder:

  • Persistent belief in the presence of an underlying serious disease eg. Cancer
  • Patient refuses to accept reassurance or negative test results

Remember:
Somatisation = Symptoms
HypoChondria = Cancer

46
Q

A 23yo male presents to his GP two weeks after a Road Traffic Accident. He is concerned about increased anxiety levels, lethargy and a headache. At the time he had a CT brain after hitting his head on the steering wheel, which revealed no abnormality. 6 months following this episode, his symptoms have resolved.
What did his original symptoms likely represent?

A

Post-concussion syndrome

47
Q

What are the typical features of ‘Post-concussion syndrome’?

A

Post-concussion syndrome is seen even after minor head trauma.

Typical features include:

  • Headache
  • Fatigue
  • Anxiety / Depression
  • Dizziness
48
Q

A 45yo man is admitted due to haematemesis. He reports drinking 120 units alcohol / week. When is the peak incidence of seizures following alcohol withdrawal?

A

36 hours

Alcohol withdrawal:

  • Symptoms: 6 - 12 hours
  • Seizures: 36 hours
  • Delirium Tremens: 72 hours
49
Q

What is the pathophysiology that leads to alcohol withdrawal following chronic alcohol consumption?

A
  • Chronic alcohol consumption:
    > Increased inhibitory GABA
    > Decreased NMDA-type glutamate transmission
  • Alcohol withdrawal is thought to lead to the opposite:
    > Decreased inhibitory GABA
    > Increased NMDA glutamate transmission
50
Q

What are the features of alcohol withdrawal seen at:

i) 6 - 12 hours
ii) 36 hours
iii) 48 - 72 hours

A 
Features of alcohol withdrawal:
i) 6 - 12 hours: Tremor, sweating, tachycardia, anxiety
ii) 36 hours: Peak incidence of seizures 
iii) 48 - 72 hours: Delirium Tremens
> Coarse tremor
> Confusion
> Delusions
> Auditory and visual hallucinations
> Fever
> Tachycardia
51
Q

How should you manage a patient who is suffering from Alcohol Withdrawal?

A
  • Patients with a history of complex withdrawals from alcohol (e.g. Delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised.

First line: Benzodiazepines eg. Chlordiazepoxide. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol.

Carbamazepine is also effective in treatment of alcohol withdrawal.

Phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures.

MRCP Part 1 (16 decks)

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