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MRCP Part 1 > Psychiatry 3 > Flashcards

Psychiatry 3 Flashcards

1
Q

A 26yo female presents to the Emergency Department feeling suicidal after the breakdown of her relationship 2 weeks ago. She reports of being fearful of being on her own as her partner made all major decisions in their relationship as she is not capable of making correct choices. She has tried online dating since her relationship broke down but despite multiple dates has not yet found a new partner.
She advises you that she was previously diagnosed with a personality disorder. What is the most likely diagnosis?

A

Dependent personality disorder.

Patients with dependent personality disorder require excessive reassurance from others, seek out relationships, and require others to take responsibility for major life decisions.
They feel they are unable to look after themselves and become fearful when left to do so.

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2
Q

Describe a patient with Borderline Personality disorder.

A
  • Characterised by emotional instability, impulsive behaviour and intense but unstable relationships with others.
  • Patients often fear abandonment but do not seek out excessive reassurance and are able to make life decisions.
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3
Q

A 19yo woman presents to the Emergency Department having taken an overdose of 40x500mg paracetamol tablets and 400ml vodka.
She took the overdose because her boyfriend is going away for 2 weeks on a course and she fears abandonment.
This is her 4th OD in 3 years. She is known to the Police following an episode of reckless driving.
On arrival, she is tearful and upset. She tells you she did it because her boyfriend is leaving her.
She is given activated charcoal. All other observations are normal.
What is the most likely diagnosis?

A

Borderline Personality Disorder: instability in moods, behaviour and relationships.

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4
Q

For a person to be diagnosed with Borderline Personality disorder, they must have at least 5 out of 8 symptoms. What are these 8 symptoms?

A
  1. Extreme reactions eg. panic, rage, actions to avoid abandonment, whether real or perceived.
  2. Pattern of intense / stormy relationships with family and friends.
  3. Distorted and unstable self image which can result in sudden changes in feelings, opinions, values etc.
  4. Impulsive, often dangerous, behaviours.
  5. Recurring suicidal behaviours / threats of self-harming
  6. Chronic feelings of emptiness and/or boredom
  7. Inappropriate, intense anger or problems controlling anger
  8. Having stress-related paranoid thoughts or severe dissociative symptoms
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5
Q

A patient with a history of depression presents for review.
Which one of the following suggests and increased risk of suicide?
- Being 25 years old
- Hx of arm cutting
- Being married
- Female sex
- Having a busy job

A

History of arm cutting:
Whilst arm cutting may sometimes be characterised as attention seeking or ‘releasing the pain’, studies show that any history of deliberate self harm significantly increases the risk of suicide.

Employment is a protective factor.

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6
Q

List some factors which have been shown to be associated with an increased risk of suicide.

A
  • Male sex
  • Hx of deliberate self harm
  • Alcohol or drug misuse
  • Hx of Mental illness eg. Depression, Schizophrenia
  • Hx of chronic disease
  • Advancing age
  • Unemployment
  • Social isolation / living alone
  • Being unmarried, divorced or widowed.
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7
Q

If a patient has attempted suicide, there are a number of factors associated with an increased risk of completed suicide. What are these?

A
  • Efforts to avoid discovery
  • Planning
  • Leaving a written note
  • Final acts such as sorting out finances
  • Violent method
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8
Q

There are a number of factors which reduce the risk of a patient committing suicide. List some of these.

A
  • Family support
  • Having children at home
  • Religious belief
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9
Q

A woman who gave birth 5 days ago presents for review as she is concerned about her mood. She is having difficulty sleeping and feels generally anxious and tearful. Since giving birth, she has also found herself snapping at her husband. This is her first pregnancy, she is not breast feeding and there is no history of mental health disorders in the past. What is the most appropriate management?

A

Explanation and reassurance.

This woman has the baby-blues which is seen in around two thirds of women. Whilst poor sleeping can be a sign of depression, it is to be expected with a new baby.

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10
Q

You review a 55yo woman who has become dependent on Temazepam, which was initially prescribed as a hypnotic. She is keen to end her addiction to Temazepam and asks for help. Her current dose is 20mg ON. What is the most appropriate strategy?

A

Switch to the equivalent Diazepam dose then slowly withdraw over the next 2 months.

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11
Q

What is the mechanism of action of Benzodiazepines?

How does this relate to their use?

A

BZDs enhance the effect of the inhibitory neurotransmitter GABA by increasing the FREQUENCY of Chloride channels.

Therefore, they are used for a variety of purposes:

  • Sedation
  • Hypnotic
  • Anxiolytic
  • Anticonvulsant
  • Muscle relaxant
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12
Q

Why should we be careful about prescribing BZDs? What’s the advice regarding BZD prescriptions?

A

Patients commonly develop a tolerance and dependance to BZDs and care should therefore be exercised on prescribing these drugs.

The Committee of Safety of Medicines advises that Benzodiazepines are only prescribed for a short period of time (2-4 weeks).

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13
Q

What is the BNF’s advice on ‘How to withdraw a Benzodiazepine’?

A
  • The dose should be withdrawn in steps of about 1/8 (range of 1/10 to 1/4) of the daily dose every fortnight.

Suggested protocol for patients experiencing difficulty:

  • Switch patient to the equivalent dose of diazepam
  • Reduce dose of Diazepam every 2-3 weeks in steps of 2 or 2.5mg
  • Time needed for withdrawal can vary from 4 weeks to a year or more.
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14
Q

If patients withdraw too quickly from BZDs, they may experience BZD withdrawal syndrome. When does this occur and what are the features?

A 
BZD withdrawal syndrome 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
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15
Q

What does the phrase ‘Frequently Bend - During Barbecue’ refer to?

A

‘Frequently Bend - During Barbecue’ refers to how GABA-A drugs work:

  • Benzodiazepines increase the frequency of Chloride channels
  • Barbituates increase the duration of Chloride Channel opening.
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16
Q

You are looking after a 36yo female patient on the ward when you become concerned regarding her behaviour towards you. She has made a number of sexually inappropriate comments and on your last review she was wearing seductive underwear. She is often disruptive on the ward making, and is easily encouraged by other patients.
Your consultant advises you to avoid seeing the patient on her own and that he is aware the patient has a personality disorder.
What is her most likely diagnosis?

A

Histrionic Personality Disorder: characterised by inappropriate sexual seductiveness, suggestibility and intense relationships.

They can develop intense relationships but at other times read more into the intimacy of a relationship than there actually is.

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17
Q

The sister of a 34yo man comes to see you in clinic as she is worried her brother may have a personality disorder. She reports her brother has always had a heightened opinion of himself and often expresses delusional thoughts regarding his potential for success as a banker believing he is capable of making millions.
He does not seem perturbed when he talks of others’ failures. She remembers he behaved similarly when they were growing up and was unsympathetic towards her when she had to resit her finals due to ill health.
What personality disorder is she describing?

A

Narcissistic Personality Disorder:
- Narcissistic personalities lack empathy, have a sense of entitlement and take advantages of others to achieve their own need.

  • The brother may not qualify as ‘having a personality disorder’ if the behaviour does not cause personal distress or prevent him functioning socially.
  • Many personality disorders have symptoms which have been present since childhood and into adult life.
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18
Q

Which one of the following interventions is most likely to be beneficial in a patient with Schizophrenia?

  • Counselling
  • Supportive psychotherapy
  • Social skills training
  • Adherence therapy
  • Cognitive behavioural therapy
A

Cognitive Behavioural Therapy

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19
Q

What are the 2009 NICE guidelines for management of Schizophrenia?

A
  • Oral atypical antipsychotics are first line
  • CBT should be offered to all patients
  • Close attention should be paid to cardiovascular disease in schizophrenic patients (linked to antipsychotic medication and high smoking rates).
20
Q

You are considering prescribing an SSRI for a patient with depression.
Which class of drug is most likely to interact with a SSRI?
- Beta-blocker
- Thiazolidinediones
- Tetracycline
- Statin
- Triptan

A

Triptan

Triptans should be avoided in patients taking an SSRI due to the increased risk of Serotonin syndrome.

21
Q

A 54yo man presents with a variety of symptoms that have been present for the past 9 years. Numerous investigations and review by a variety of specialties have indicated no organic basis for his symptoms. This is an example of which disorder?

A

Somatisation disorder:

  • multiple physical SYMPTOMS present for at least 2 years
  • Patient refuses to accept reassurance or negative test results.
22
Q

An 84yo female has been an inpatient in a psychiatric ward with a fixed belief that her insides are rotting as she is deceased.
What is this type of delusion known as?

A

Cotard delusion

23
Q

What is ‘Cotard syndrome’?

A

Cotard Syndrome:

  • 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.
24
Q

What is Cotard syndrome associated with?

A
  • Severe depression and psychotic disorders.
25
Q

What is Othello syndrome?

A

A delusional belief that a patient’s partner is committing infidelity despite no evidence of this.
It can often result in violence and controlling behaviour.

26
Q

What is ‘De Clerambault syndrome’?

A

De Clerambault syndrome (aka Erotomania):

  • patient believes that a person of higher social or professional standing is in love with them
  • Often this presents with people who believe celebrities are in love with them.
27
Q

What is ‘Ekbom syndrome’?

A

Ekbom syndrome (aka Delusional parasitosis):

  • the belief that they are infected with parasites or have ‘bugs’ under their skin
  • Can vary from the classic psychosis symptoms in narcotic use where the user can ‘see’ bugs crawling under their skin, or can be a patient who believes they are infested with snakes.
28
Q

What is ‘Capgras delusion’?

A

Capgras delusion is the belief that friends or family members have been replaced by an indentical-looking imposter.

29
Q

A 64yo male who has been on long term Chlorpromazine presents with repetitive eye blinking. He reports he is unable to control this and is worried about what might be causing it. He is otherwise well in himself and has no visual disturbance. He has a normal facial and ocular examination with the exception of rapid blinking.
What is the most likely cause of his symptoms?

A

Tardive dyskinesia: the patient has been on a long term antipsychotic (Chlorpromazine) and has developed late-onset EPSEs (extra-pyramidal side effects).

30
Q

How might Tardive dyskinesia present?

A

Patients typically develop lip-smacking, jaw pouting or chewing. Less commonly, they may develop repetitive blinking to tongue poking.
This is often involuntary and difficult to treat.
Where possible, replacing the antipsychotic may help some patients or alternatively, a trial of tetrabenazine may provide some relief.

31
Q

Which class of drug may precipitate Parkinsonism?

A

Conventional antipsychotics.

Patients experience tremor, blank facies, bradykinesia and muscle rigidity.

32
Q

What is Blepharospasm?

A
  • Involuntary twitching or contraction of the eyelid.
  • It is a focal dystonia which commonly lasts only a few days but can be lifelong.
  • Patients may be light sensitive and experience periods where the eye clamps shut.
  • The cause is typically unknown but commonly occurs due to stress or fatigue
33
Q

A 42yo woman presents for review. Her husband reports that she has had an argument with their sone which resulted in him leaving home. Since this happened she has not been able to speak.
Clinical examination of her throat and chest in unremarkable.
Which term best describes this presentation?

A

Psychogenic aphonia:

- considered to be a form of conversion disorder

34
Q

Aphonia describes the inability to speak. List 2 main causes for this.

A
  1. Recurrent laryngeal nerve palsy (eg. post-thyroidectomy)

2. Psychogenic e.g. psychogenic aphonia (considered to be a form of conversion disorder)

35
Q

Which of the following SSRIs has the highest incidence of discontinuation symptoms?

  • Paroxetine
  • Citalopram
  • Escitalopram
  • Fluoxetine
  • Sertraline
A

Paroxetine

36
Q

A 47yo alcoholic has been brought to the Emergency Department by his brother.
His brother states that he has been confused for the last few days and has fallen over a few times. On examination, he has an unsteady gait. He cannot remember the first female Prime Minister of the UK or the journey to the Emergency Department. He claimed he went to the park yesterday, which his brother states is untrue.
Considering the clinical picture, what is the most likely diagnosis?

A

Korsakoff’s Syndrome:
- a complication of Wernicke’s encephalopathy.
Features include:
- Anterograde amnesia (unable to form new memories)
- Retrograde amnesia (unable to recall past memories)
- Confabulation (making up new memories)

Wernicke’s encephalopathy is characterised by:

  • Ataxia
  • Ophthalmoplegia
  • Confusion
37
Q

Describe the pathophysiology of Korsakoff’s Syndrome.

A
  • Marked memory disorder often seen in alcoholics
  • Thiamine deficiency causes damage and haemorrhage to the mamillary bodies of the hypothalamus and the medial thalamus
  • Korsakoff’s often follows on from untreated Wernicke’s encephalopathy.
38
Q

List 3 features of Korsakoff’s Syndrome.

A
  • Anterograde amnesia: inability to acquire new memories
  • Retrograde amnesia: unable to recall past memories
  • Confabulation: making up new memories.
39
Q

An 88yo woman is brought to her GP by her daughter because of new memory problems. She did not want to attend as she is worried about her memory and does not want to be diagnosed with dementia. She scores 12/30 on a MMSE.
Her memory is globally impaired with failure to retain new information as well as failure to remember important events from her life. Her daughter reports this has been ongoing for 2 months and that her mum was previously fine with no cognitive concerns.
She is struggling with sleep and her appetite has reduced significantly in this time although the patient denies this.
What is the most likely cause of her memory impairment?

A

Depression

It can often be difficult to ascertain the cause of memory impairment in a single encounter, but there are 3 main causes to consider:

  • A dementia process
  • An acute delirium
  • Depression (aka pseudo dementia)
40
Q

List some factors which would suggest a diagnosis of Depression, rather than Dementia.

A

Depression:

  • short history, rapid onset
  • biological symptoms eg. weight loss, sleep disturbance
  • patient worried about poor memory
  • reluctant to take tests, disappointed with results
  • MMSE is variable
  • Global memory loss in depression (Dementia characteristically causes recent memory loss).
41
Q

Which one of the following symptoms may indicate mania rather than hypomania?

  • Predominantly elevated mood
  • Delusions of grandeur
  • Increased appetite
  • Flight of ideas
  • Irritability
A

Delusions of grandeur

42
Q

What are the features of ‘Mania’?

A
  • Lasts for at least 7 days: causes severe functional impairment in social and work setting
  • May require hospitalisation due to risk of harm to self or others
  • May present with psychotic symptoms eg. delusions of grandeur, auditory hallucinations (not seen in hypomania).
43
Q

What are the features of ‘Hypomania’?

A
  • A lesser version of mania
  • Last 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 hospitalisation
  • Does not exhibit any psychotic symptoms
44
Q

List some ‘mood’ symptoms which are common to mania and hypomania.

A
  • Predominately elevated mood

- Irritable

45
Q

List some ‘speech and thought’ symptoms which are common to both mania and hypomania.

A
  • Pressured speech
  • Flight of ideas: characterised by rapid speech with frequent changes in topic based on associations, distractions or word play
  • Poor attention
46
Q

Describe some behavioural symptoms which are common to mania and hypomania.

A
  • Insomnia
  • Loss of inhibitions: sexual promiscuity, overspending, risk-taking
  • Increased appetite.

MRCP Part 1 (16 decks)

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