Psychiatry

Question 1

what is a confabulation?

Answer 1

In psychiatry, confabulation is a disturbance of memory, defined as the production of fabricated, distorted, or misinterpreted memories about oneself or the world, without the conscious intention to deceive.

Question 2

A 24-year-old man is admitted to the acute psychiatric ward with a history of psychotic symptoms and is given a diagnosis of schizophrenia.

Which of the following symptoms is a first-rank symptom of schizophrenia?

A. Nihilistic delusion.	   
B. Confabulation.	   
C. Pressured speech.	   
D. Thought insertion.	   
E. Apathy.

Answer 2

The first-rank symptoms of schizophrenia include:
auditory hallucinations:

• thought withdrawal, insertion, and interruption.
• thought broadcasting.
• somatic hallucinations.
• delusional perception.
• feelings or actions experienced as made or influenced by external agents.

Question 3

A research student wishes to conduct a project on anxiety disorders and wishes to use a standardized classification system.

Which of the following is the classification system used for mental illness?

A. ICD-10	   
B. ICD-9	   
C. SCID	   
D. SCAN	   
E. CAGE

Answer 3

A. ICD-10

Question 4

An 8-year-old boy is referred with behavioral problems to the Child Psychiatry Department. He is always active at home and moves from task to task. He finds it difficult to concentrate to read or watch TV. He often puts himself into dangerous situations like climbing onto high roofs. His performance at school is poor where he is distractible and causes distractions to others.

What is the most likely diagnosis?

A. Mania.	   
B. Schizophrenia.	   
C. Somnambulism.	   
D. Conduct disorder.	   
E. Attention Deficit and Hyperactivity Disorder.

Answer 4

E. Attention Deficit Hyperactivity Disorder

Question 5

Well done, correct.

An elderly man has been admitted to hospital with acute onset disorientation, visual hallucinations, and agitation. He has no psychiatric history and lives alone and requires no support.

What is the most likely diagnosis?

A. Alzheimer's Disease.	   
B. Lewy Body Dementia.	   
C. Schizophrenia.	   
D. Depression.	   
E. Delirium.

Answer 5

E. Delirium

Question 6

You are a GP and have diagnosed a 27 year old lady with depression. You are confident that she does not require to be treated in hospital and wish to start her on treatment.

Which of the following would be appropriate first-line treatment?

A. Benzodiazepines.	   
B. MAOI.	   
C. SNRI.	   
D. SSRI.	   
E. Tricyclic.

Answer 6

D. SSRI

Question 7

A 29 year old junior doctor is being treated for depression with CBT.

Which of the following is a term used in CBT?

A. Interpersonal Map	   
B. Negative Automatic Thoughts	   
C. Pre-contemplation	   
D. Separation Anxiety	   
E. Thought Blocking

Answer 7

B. Negative automatic thoughts

Question 8

A middle aged man is admitted to hospital with gall stones. Part of the admission history is to screen for alcohol problems.

Which of the following is an appropriate questionnaire to screen for alcohol problems?

A. FAST.	   
B. GCS.	   
C. BDI.	   
D. MADRS.	   
E. MOCA.

Answer 8

A. FAST

Question 9

A 23 year old man is assessed by his GP. He has a severe dermatological condition affecting his hands which is caused by his washing them 13 times before he leaves his house.

What is the most likely diagnosis?

A. Autistic Spectrum Disorder	   
B. Contact dermatitis	   
C. Delusional Disorder	   
D. Obsessive Compulsive Disorder	   
E. Psoriasis

Answer 9

D. Obsessive Compulsive Disorder

Question 10

A 67 year old woman arranges for her daughter to be able to manage her money as her own mother developed dementia at the age of 70.

power to use in this situation?

A. Assessment Order	   
B. Guardianship Order	   
C. Place of Safety Order	   
D. Power of Attorney	   
E. Restriction Order

Answer 10

D. Power of Attorney

Question 11

A 24 year old man has recently been started on new medication by his psychiatrist. One of the side effects is an unpleasant sensation of restlessness.

What is the correct term for this?

A. Akathisia	   
B. Anhedonia	   
C. Catatonia	   
D. Dysarthria	   
E. Dystonia

Answer 11

A. Akathisia

Question 12

A 28 year old man has recently started on antipsychotics. He has been told about a side effect of muscle stiffness and contraction sometimes caused by antipsychotics.

What is the correct term for this?

A. Akathisia	   
B. Anhedonia	   
C. Catatonia	   
D. Dysarthria	   
E. Dystonia

Answer 12

e. Dystonia

Question 13

79 year old man who has had two hospital admissions for depression in the past is brought to the GP by his daughter. She is concerned that he is spending lots of money, has a reduced need to sleep, is full of energy and wants to run a marathon.

Which is the most likely diagnosis?

A. Alzheimer’s Disease	   
B. Bipolar Affective Disorder	   	
C. Delusional Disorder	   
D. Lewy Body Dementia	   
E. Vascular Dementia

Answer 13

B. Bipolar Affective Disorder

Question 14

You are a psychiatrist treating a 34 year old woman with depression. You are confident of the diagnosis. You have already tried two antidepressants and the second has had only partial effect. Her mood has lifted slightly but she complains of poor sleep, lack of energy and motivation and poor appetite.

Which of the following is the most appropriate next step?

A. Add amphetamine based stimulant drugs	   
B. Add lithium	   	
C. Add thyroxine	   
D. Psychosurgery	   
E. Stop the medication

Answer 14

B. Add lithium

Question 15

A 28 year old woman is an inpatient in the general adult ward. She is being treated for schizophrenia and her symptoms are improving on medication. She is allowed to go to the cinema with a friend and on return to the ward is convinced the nurses have been replaced by aliens, the radio is playing songs especially for her and she can hear voices telling her to sit up all night.

What is the most appropriate investigation to order?

A. Blood glucose	   
B. CT Scan	   
C. Full Blood Count	   
D. Temperature	   
E. Urinary drug screen

Answer 15

E. Urinary Drug Screen

Question 16

treatments for cerebral palsy based pain?

Answer 16

1. psychological treatments
2. paracetamol
3. opioids
4. amitriptyline
5. clonidine

Question 17

Prevalence of incontinence in those living in institutions? (Nursing home, residential care, hospital care)

Answer 17

Residential care 25%
Nursing home care 40%
Hospital care 50-70%

Question 18

Marrow tissue tumours

Answer 18

1. malignant: Ewing’s sarcoma, lymphoma, myeloma

Question 19

Where do Rivaroxaban, Edoxaban apixaban act in the clotting process?

Answer 19

They act on Factor Xa - preventing the formation of thrombin from prothrombin

• thrombin is required for the formation of fibrin from fibrinogen

Question 20

When is a structural scoliosis at its most obvious?

Answer 20

When bent forward into flexion

Question 21

What does paracetamol treat well?

Answer 21

1. Mild pain (on its own)

2. Mod-severe pain (with other drugs)

Question 22

What safety precautions are needed when taking a psychiatric history?

Answer 22

o	USUALLY NO SAFETY PRECAUTIONS ARE NEEDED as it is unusual for psychiatric patients to be violent
	Inform staff who you are going to interview and where
	Attempt to predict episode
•	Autonomic over-activity
•	Posture
•	Verbal aggression
	Consider risk assessment
o	If UNCOMFORTABLE, END THE INTERVIEW

Question 23

What is included in a psychiatric history?

Answer 23

o	Very similar to a normal history
	Presenting complaint(s)
	History of presenting complaint(s)
	Past Medical History
	Past Psychiatric History
	Current and recent medication
	Social history
•	Alcohol & drug use
•	Smoking
•	Social circumstances
•	Main relationships/supports/carers
	Family History of Psychiatric Illness
	Personal History
•	Developmental milestones
•	Schooling/Education
•	Occupational History
•	Relationships
•	Pre-morbid personality

Question 24

What should be included in the introduction of the psychiatric history?

Answer 24

o Introduction
 Greet verbally and introduce self
 Orientate and check
• Explain purpose of the interview
• Advise of likely duration of interview (approx. one hour)
• Advise of note taking, confidentiality, and that will likely be shared with the team
 Use the introduction to orientate the patient and establish where they will sit etc.
 Concerns or questions?

Question 25

when taking a psychiatric history, what questions do you want to ask when discussing:

• referral
• presenting complaint
• history of presenting complaint

Answer 25

o Referral
 Why?
 Who?
 What might be going on?
• Ask questions to confirm or refute
 What were the circumstances of the referral? (e.g. informal or formal)
o Presenting complaint
 “can you tell me in your own words why you are here?”
• Record each one (in their own words)
• Come back to each one in turn
 Clarify:
• “what’s been the trouble?”
• “why have you come to see me?”
• “what do you feel is the problem?”
• “How have you been feeling recently?”
• “tell me how it started”
• “when did you last feel well in yourself?”
• “what was the first thing you noticed?”
• “what happened after that?”
• “have you noticed anything else different from usual?”
o History of presenting complaint
 Clarify each point in turn
• Onset, precipitants, course, severity
o Establish what was happening when they started
• Associated symptoms
o Ask about extras after the patient has finished volunteering symptoms
o “what other changes have your partner/family/friends noticed in you?”
o Systematic enquiry and check lists (e.g. ICD10)
 Depression
 Obsessions
 Anxiety
 psychosis
• Timing
• Effects on daily living
• Is it getting better or worse?
• Has it responded to any treatment?
o Have they recently started any treatment?
o Are they taking their medications?
• What are the most troublesome symptoms?
• Suicidal/homicidal thoughts?
o Intention
o Planning

Question 26

what are the aspects to consider when asking about

• family history
• past medical history
• current and recent medication

Answer 26

o Family history
 Parents, siblings, grandparents, etc.
 Age, employment, circumstances, health problems, quality of relationship (ability to start and maintain)
 Major mental illness in more distant relatives is important
 Genogram can be helpful
o Past medical history
 Developmental problems
 Head injuries
 Endocrine abnormalities
 Substance abuse: liver damage, oesophageal varices
 Peptic ulcers
• Other stress related conditions such as hypertension
o Current and recent medication
 Tablet and injections
• Compliance?
 Recent medication
 Any discontinued drugs in the past 6 months
 How long for? What dose?
 Adverse reactions and allergies

Question 27

when taking the psychiatric history what are the important questions to ask in gather:

• social history
• personal history

Answer 27

o	Social history
	Current social circumstances
	Current occupation
	Current financial situation/stressors
	Smoking
	Alcohol/illict drug use
•	Regular or intermittent?
•	Amount (units)
•	Pattern
•	Dependence/withdrawal symptoms
•	Impact on work, relationships, money, police
•	Screening questionnaire e.g. CAGE
	Current relationship/stressors
	Children – contact
o	Personal history
	Developmental milestones
	Early life
	Schooling (have they achieved appropriately since school?)
	Occupational
	Relationships
•	Sexual
•	Marital
•	Can they start and maintain relationships?
	Financial
	Friendships, hobbies, interests

Question 28

after considering the following in a psychiatric history:

• introduction
• referral
• presenting complaint
• history of presenting complaint
• family history
• past medical history
• current and recent medication
• social history
• personal history

what other topics may you want to cover?

Answer 28

o Forensic history
 “have you ever been in contact with the police? Charged with any crime?”
• Offences included in the sentences
 Recidivism (relapsing)
 ….particularly about violent or sexual crimes
o Pre-morbid personality
 Rarely comprehensive
• Can’t really achieve without getting an objective third person view
 Emphasis on consistent patterns of behaviour, interaction, mood
 “how would your best friend describe you as a person?”
o Mental state examination

Question 29

What are psychopathology, descriptive psychopathology and phenomenology?

Answer 29

o Psychopathology: psychopathology is concerned with abnormal experience, cognition and behaviour
o Descriptive psychopathology: descriptive psychopathology describes and categorises the abnormal experience as described by the patient
o Phenomenology: phenomenology, in psychiatry, refers to the observation and understanding of the psychological event or phenomenon so that the observer can, as far as possible, know what the patient’s experience feels like

Question 30

what are the aspects of the Mental State Examination? ?

Answer 30

1. Appearance
2. Behaviour
3. Affect (emotions conveyed and observed objectively during an interview)
4. mood (patients subjective report)
5. speech
6. thoughts/thinking
7. beliefs
8. percepts
9. cognitive function
10. insight
11. suicide/homicide

Question 31

what are mood disorders?

Answer 31

o Mood disorders are disorders of mental status and function where altered mood is the (or a) core feature
 A term referring to states of depression and of elevated mood (to a point of problem) = mania
o These are the commonest group of mental disorders

Question 32

generally, what is depression?

Answer 32

o Depression is a term to describe a state of feeling, or mood, that can range from normal experience to severe, life-threatening illness
o Depression is a ‘systemic’ symptom (complaint) with similarities to fatigue and pain
o Depression is typically considered as a form of sadness (and not just and absence of happiness)

Question 33

When does depression become abnormal?

Answer 33

o	There is no clear or convenient division
	It is often a matter of perspective
o	In psychiatry emphasis is placed on:
	Persistence of symptoms
•	≥ 2 weeks (although it is often much longer before help is sought
	Pervasiveness of symptoms
•	How encompassing is the disease?
•	Does it vary?  Or is it all the time?
	Degree of impairment
	Presence of specific symptoms or signs

Question 34

• What are the symptoms of depressive illness?

Answer 34

o The symptoms of depressive illness occur in three spheres:
 Psychological
• Change in mood
o Depression (may find diurnal variation i.e. worse in the morning)
o Anxiety – the inability to relax
o Perplexity¬ – feeling of bewilderment (particularly in puerperal illness)
o Anhedonia – inability to get pleasure from normal sources of enjoyment
• Change in though content
o Guilt (disproportionate)
o Hopelessness
o Worthlessness
o Any neurotic symptomatology (e.g. hypochondriasis, agoraphobia, obsessions & compulsions, panic attacks)
o Idea of reference – perceiving something normal to be something other than it is e.g. secret messages in songs
o Delusions and hallucinations (if depression is severe)
 Delusions – strong belief/idea even when there is evidence to the contrary e.g. rotting inside
 Hallucinations – smell the rotting
 Physical
• Change in bodily function – “feel like they’ve put on a lead cloak”
o ↓ energy – fatigue
o Difficulty sleeping – getting to sleep; staying asleep; early morning waking
o ↓ appetite → weight loss
o ↓ libido
o Constipation
o Pain
• Change in psychomotor functioning
o Agitation
o Retardation = a slowing of motor responses including speech
 Stupor = a state of extreme retardation in which consciousness is intact. The patient stops moving, speaking, eating and drinking. On recovery they can describe clearly events which occurred whilst stuporose
 social
• loss of interests
• irritability
• apathy = lack of interest in own surroundings
• withdrawal, loss of confidence, indecisive
• loss of concentration, registration and memory

Question 35

what are some of the physical manifestations of depression?

Answer 35

• Change in bodily function – “feel like they’ve put on a lead cloak”
o ↓ energy – fatigue
o Difficulty sleeping – getting to sleep; staying asleep; early morning waking
o ↓ appetite → weight loss
o ↓ libido
o Constipation
o Pain
• Change in psychomotor functioning
o Agitation
o Retardation = a slowing of motor responses including speech
 Stupor = a state of extreme retardation in which consciousness is intact. The patient stops moving, speaking, eating and drinking. On recovery they can describe clearly events which occurred whilst stuporose

Question 36

DEpression often presents with psychological aspects of pathology. this may be change in mood or change in thought content. suggest 4 pathological changes in thought content that may be symptomatic of a diagnosis of depression

Answer 36

• Change in though content
o Guilt (disproportionate)
o Hopelessness
o Worthlessness
o Any neurotic symptomatology (e.g. hypochondriasis, agoraphobia, obsessions & compulsions, panic attacks)
o Idea of reference – perceiving something normal to be something other than it is e.g. secret messages in songs
o Delusions and hallucinations (if depression is severe)
 Delusions – strong belief/idea even when there is evidence to the contrary e.g. rotting inside
 Hallucinations – smell the rotting

Question 37

how is depression diagnosed with ICD-10?

Answer 37

o Must last for at least two weeks
o Must never have had a hypomanic or manic episode in their lifetime
o Must not be attributable to psychoactive substance use or an organic mental disorder
 If there are psychotic symptoms or stupor then = severe depression with psychotic symptoms
• Need to exclude other psychotic illnesses like schizophrenia first

Question 38

What is somatic syndrome in depression?

Answer 38

o Marked loss of interest or pleasure in activities that are normally pleasurable
o Lack of emotional reactions to events or activities that normally produce an emotional response
o Waking two hours before normal time
o Depression worse in the morning
o Objective evidence of psychomotor agitation or retardation
o Marked loss of apetite
o Weight loss – 5%+ of body weight in a month
o Marked loss of libido

Question 39

What are the criteria for mild, moderate and severe depression?

Answer 39

o All must fulfil the general criteria
o + have at least two of:
 Depressed mood that is abnormal for most of the day almost every day for the past two weeks, largely uninfluenced by circumstances
 Loss of interest or pleasure
 Decreased energy or increased fatiguability
o + 2 of the following for mild; 4 for moderate; and 6 for severe:
 Loss of confidence or self esteem
 Unreasonable feelings of guilt or self-reproach or excessive guilt
 Recurrent thoughts of death by suicide or any suicidal behaviour
 Decreased concentration
 Agitation or retardation
 Sleep disturbance of any sort
 Change in appetite

Question 40

What is the epidemiology of post-natal depression?

Answer 40

o There is a 7x ↑ in psychiatric admissions in the month following childbirth with an increased risk lasting for 24 months
o 75% of women experience the baby “blues” within 2 weeks
o 10% of women develop a major depressive disorder within 3-6 months
o ‘puerperal psychosis’ occurs in 1 in 500 deliveries with a risk of recurrence of 1-3 with subsequent deliveries

Question 41

• What are some differential diagnosis for depression?

Answer 41

o	Normal reaction to life event
o	SAD (seasonal affective disorder)
o	Dysthymia – more mild than depression
o	Cyclothymia – more mild than bipolar
o	Bipolar
o	Stroke, tumour, dementia
o	Hypothyroidism, Addison’s, Hyperparathyroidism
o	Infections – influenza, infectious mononucleosis, hepatitis, HIV/AIDS
o	Drugs

Question 42

What are the treatments for depression?

Answer 42

o Antidepressants
 SSRIs (Selective Serotonin Reuptake Inhibitors
 Tricyclic antidepressants (TCAs)
 Monamine Oxidase Inhibitors (MAO Inhibitors)
 Other antidepressants
o Psychological Treatments
 Cognitive behavioural therapy, interpersonal therapy, individual dynamic psychotherapy, family therapy
o Physical treatments
 Usually reserved for more severe disease
 Electro-convulsive therapy, psychosurgery, deep brain stimulation, vagus nerve stimulation

Question 43

What is the epidemiology of depression?

Answer 43

o lifetime prevalence rate (n per 100): 2.9 - 12
 point prevalence rate of depression: 3.7 - 7.7
• lifetime risk for less severe manifestations - 20
o rates for females exceed rates for males - 2:1
o highest risk from age 18-44 (median 25)
 mean age of onset = 27
 onset during old age is not unusual
o no overall association with socioeconomic status
 MDD less common in those employed
 MDD less common in those financially independent (N.B. - direction of effect)
 association with lower educational attainment
 stable marriage negatively associated with MDD
o increased risk in 1st0 relatives where proband has MDD (3x) or BPD (2x)
 twin studies: MZ ‘v’ DZ = 27% ‘v’ 12%
o onset of depression (first episode) associated with excess of adverse life events
 ‘exit events’ - separations, losses

Question 44

What is mania?

Answer 44

o Mania is a term to describe a state of feeling, or mood, that can range from near-normal experience to severe, life-threatening illness (suicide is a big risk)
o Mania is rarely a symptoms: it is often associated with grandiose ideas, disinhibition, loss of judgement (has similarities to the mental effects of stimulant drugs (AMPH, cocaine)
o Mania is typically considered as a form of pathological, inappropriate elevated mood

Question 45

When is an elevated mood mania?

Answer 45

o There is no clear and convenient division
o It is often a matter of judgement of deviation from ‘normal self’
o In psychiatry emphasis is placed on:
 Persistence of symptoms
 Pervasiveness of symptoms
 Degree of impairment
 Presence of specific symptoms or signs

Question 46

• What are the different types of mania according to the ICD-10?

Answer 46

o Hypomania
 Lesser degree of mania, no psychosis
 Mild elevation of mood for several days on end
 Increased energy and activity, marked feeling of wellbeing
 Increased sociability, talkativeness, overfamiliarity, increased sexual energy, decreased need for sleep
 May be irritable
 Concentration reduced, new interests, mild overspending
 Not to the extent of severe disruption of work or social rejection
o Mania without psychotic symptoms
o Mania with psychotic symptoms
 1 week of symptoms severe enough to disrupt ordinary work and social activities more or less completely
 Elevated mood, increased energy, over activity, pressure of speech, decreased need for sleep
 Disinhibition
 Grandiosity
 Alteration of senses
 Extravagant spending
 Can be irritable rather than elated
o Other manic episodes
o Manic episode, unspecified

Question 47

What are differential diagnosis for mania?

Answer 47

o	Psychiatric
	Mixed affective state
	Schizoaffective disorder
	Scizophrenia
	Cyclothymia
	ADHD
	Drugs and alcohol
o	Medical
	Stroke
	MS
	Tumour
	Epilepsy
	AIDS
	Neurosyphilis
	Endocrine – Cushing’s, hyperthyroidism, SLE

Question 48

what tools are used to measure symptoms of mania?

Answer 48

o SCID
o SCAN
o Young Mania Rating Scale (YMRS)

Question 49

What is the treatment for mania?

Answer 49

o	Antipsychotics
	Olanzapine
	Risperidone
	Quetiapine
o	Mood stabilisers
	Sodium Valproate
	Lamotrigine
	Carbamazepine
o	Lithium
o	ECT

Question 50

What is bipolar affective disorder?

Answer 50

o Bipolar affective disorder consists of repeated (2+) episodes of depression and mania/hypomania
 If there is no mania/hypomania = recurrent depression
 If there is no depression = hypomania

Question 51

What is the epidemiology of bipolar disorder?

Answer 51

o lifetime prevalence rate (n per 100) : 0.7 - 1.6
o point prevalence rate of mania : 0.08 - 0.8
o industrialised nations = non-industrialised
o rates for males = rates for females
o mean age of onset = 21 (unusual >30)
o some studies - 1/3 onset < 20
o early onset (15-19) usually with positive FH
o no differential prevalence according to income, occupation or educational status
o prevalence consistently increased in 1st0 relatives
o other forms of depression also more common

Question 52

How are mood disorders classified?

Answer 52

o European classification = ICD-10

o American, and used in research, classification = DSM-5

Question 53

What causes mood disorders?

Answer 53

o Can be a primary problem
o Can present as a consequence of another disorder or illness e.g. cancer, dementia, drug misuse or medical treatment (steroids)
 They are also often associated with anxiety symptoms and anxiety disorders

Question 54

What is the clinical course and outcome for the different affective disorders?

Answer 54

o	Major depression
	Typical episode lasts 4-6 months
	54% recovered at 26 weeks
	12% fail to recover
	80%+, where hospitalisation was needed, have further episodes
•	40% in those whose condition was mild enough to be treated in primary care
	15% die by suicide
o	Bipolar disorder/mania
	Typical manic episode lasts 1-3 months
	60% are recovered at 10 weeks
	5% fail to recover
	90% have further episodes
	1/3 have poor outcome
	1/3-1/4 have good outcome
	10% die by suicide

Question 55

What is cognitive behavioural therapy about?

Answer 55

 CBT explores how our thoughts relate to our feelings and behaviour
 It is particularly good for depression, anxiety, phobias, OCD and PTSD
 CBT focuses on the here and now
 Problem-focussed, goal-oriented
 Can be given individually, in groups, through self-help books or computer programmes

Question 56

What does the therapist in CBT do?

Answer 56

 The therapist helps the client:
• Identify thoughts, feeling and behaviours
• Assess whether thoughts are unrealistic/unhelpful
o Automatic thoughts – anxiety/fear
o Unrealistic beliefs
o Cognitive distortions – catastrophising
• The client then engages in “homework” which challenges the unrealistic or unhelpful thoughts
o Graded exposure
 Gradually builds up to e.g. putting hand in the toilet
 Response prevention

Question 57

What is the rationale behind behavioural activation theory?

Answer 57

 The idea behind behavioural activation therapy is that not enough positive reinforcement/too much punishment can contribute to depression
 The patient focuses on avoided activities
• As a guide for activity scheduling
• For a functional analysis of cognitive processes that involve avoidance
 Focus on what predicts and maintain an unhelpful response by various reinforcers
 Client is taught to analyse unintended consequences of their way of responding

Question 58

What are common avoidance activities in depression?

Answer 58

	Social withdrawal
•	Not answering the telephone
•	Avoiding friends
	Non-social avoidance
•	Not taking on challenging tasks
•	Sitting around the house
•	Spending excessive time in bed
	Cognitive avoidance
•	Not thinking about relationship problems
•	Not making decisions about the future
•	Not taking opportunities
•	Not being serious about work/studies
	Avoidance by distraction
•	Watching rubbish on TV
•	Playing on computer games
•	Gambling
•	Comfort-eating
•	Excessive exercise
	Emotional avoidance
•	Use of alcohol and other substances

Question 59

How is behavioural activation carried out?

Answer 59

 Collaborative/empathic/non-judgemental
 Structured agenda – review progress
 Small changes → build to long term goals

Question 60

What is interpersonal psychotherapy?

Answer 60

 Interpersonal psychotherapy is a treatment for depression/anxiety
 It is a time-limited treatment
• Lasts for about 12-16 weeks
 Focuses on the present

Question 61

What is the idea behind interpersonal psychotherapy?

Answer 61

	Depression often follows a disturbing change in or with a significant interpersonal event e.g.:
•	A complicated bereavement
•	A dispute
•	A role transition
•	An interpersonal deficit

Question 62

How is interpersonal psychotherapy put into practice?

Answer 62

	“sick role” given
	Construct an “interpersonal map”
•	Identify the interpersonal context
	“focus area” maintaine
•	Depressive symptoms linke to interpersonal events (weekly
	The goal:
•	Reduce depressive symptoms
•	Improve interpersonal functioning

Question 63

What are the strengths and limitations of interpersonal psychotherapy?

Answer 63

 Strengths
• ‘A’ grade evidence for treating depression
• No formal homework – may be preferable
• Client can continue to practice skills beyond the session ending
 Limitations
• Requires a degree of ability to reflect which may be difficult for some (especially in personality disordered patients)
• If the patient has poor social networks they will have limited interpersonal support

Question 64

what are the name of the photoreceptors that have a high threshold for light and operate best in daylight

Answer 64

Cones

Question 65

What is motivational interviewing?

Answer 65

 Motivational interviewing is used where behaviour change is being considered but the patient is unmotivated or ambivalent to change
 Motivational interviewing is used in treating problem drinkers
 It promotes behaviour change
• …therefore it can be used in a wide range of health care settings
 It is more effective that advice giving

Question 66

What are the principles of motivational interviewing?

Answer 66

 Express empathy
• Understand the person’s predicament
 Avoid argument
• Challenging the patient’s position will only make them defensive
 Support self-efficacy
• Patient sets their own agenda and generates, themselves, what they might consider changing
 Run with resistance

Question 67

in motivational interviewing, what are the stages of change?

Answer 67

 Pre-contemplation: the stage at which there is no intention to change behaviour in the foreseeable future. Many individuals in this stage are unaware or under-aware of their problems.
 Contemplation: the stage in which people are aware that a problem exists and are seriously thinking about overcoming it but have not yet made a commitment to take action.
 Planning: is a stage that combines intention and behavioural criteria. Individuals in this stage are intending to take action in the next month and have unsuccessfully taken action in the past year.
 Action: is the stage in which individuals modify their behaviour, experiences, or environment in order to overcome their problems. Action involves the most overt behavioural changes and requires considerable commitment of time and energy.
 Maintenance: is the stage in which people work to prevent relapse and consolidate the gains attained during action. For addictive behaviours this stage extends from six months to an indeterminate period past the initial action.

Question 68

what does FRAMES mean in motivational interviewing/alcohol brief intervention?

Answer 68

	Feedback
•	What is good? What is bad? Emphasise the link between this and the alcohol (or behaviour trying to change)
	Responsibility
•	You’re an adult; all is your choice
	Aid/Advice
	Menu
•	…of alternatives
o	E.g. ↑ drinking, drink the same amount, ↓ drinking, stop drinking
•	What do you want to do?
	Empathy
	Self-efficacy
•	Helping them believe they can do it

Question 69

what is forensic psychiatry?

Answer 69

o The area where psychiatry meets the law

o Assessment and treatment of mentally disordered offenders in various settings

Question 70

How can psychiatric interventions affect criminal proceedings?

Answer 70

o Psychiatric intervention can occur at all stages of the criminal proceedings:
 Option to divert from prosecution (section 297)
 Police/court cells
• Civil detention under the provision above
OR
• Remand to hospital for assessment under the Criminal Procedure (Scotland) Act 1995
 Post-Conviction
• Various psychiatric ‘disposals’ on a compulsion order + restriction order, guardianship order, etc.
• Treatment can also be a condition of bail or parole
 Sentenced prisoners
• May receive compulsory care and treatment in hospital in two ways:
o At sentencing the court may, in addition to imposing a custodial sentence, impose a hospital direction in terms of section 59A of the Criminal Procedure (Scotland) Act 1995 which allows prisoners to be detained initially in hospital for medical treatment in accordance with Part 16 of the Act
o Transfer for treatment direction (section 136) which allows for the transfer for sentenced prisoner to the hospital for medical treatment
 Procurator fiscal
• Diversion
• Diminished responsibility – available in cases of murder
• Criminal Justice and Licensing (Scotland) Act 2010 outlines statutory basis for criminally responsible and grounds for being found unfit for trial

Question 71

What is the sentencing for murder and how can this be affected by mental disorders?

Answer 71

o Murder carries a mandatory life sentence when the offender is of sound mind and had malice aforethought
o If the criteria for murder is not met = Manslaughter/culpable homicide
 E.g. can be reduced to this on the grounds of diminished responsibility: “if the person’s ability to determine or control conduct for which a person would otherwise be convicted of murder was, at the time of the conduct, substantially impaired by reason of abnormality of the mind”

Question 72

How is manslaughter/culpable homicide on the grounds of diminished responsibility got?

Answer 72

o The procurator fiscal need two psychiatric reports
o Fitness to plead
o Need to be grounds for diminished responsibility
o Alleged offender examined soon after arrest

Question 73

Where are forensic psychiatry patients treated and where have they come from?

Answer 73

o In-patients
 From courts, prisons, secure hospital, general wards
o Out-patients
 Hospital based, prisons
o Psychiatric reports
 Parole board, procurator fiscal, sheriff

Question 74

How common is criminal behaviour in mentally disordered (particularly psychotic) patients?

Answer 74

o Most psychotic patients are neither criminal nor violent
 A small number of offenders with major mental illness perpetrate serious violence
o There is a clear association demonstrated between major mental disorder and violence in the last 15-20 years
 Crime is more associated with YOUTHFULNESS
o Much of it goes unreported or unrecorded
o Much more common in men

Question 75

What is the relationship between crime and mental disorder?

Answer 75

o Complex relationship
o Issue of responsibility
 Not criminally responsible as grounds for acquittal and diminished responsibility
o Compulsion orders +/- restriction or transfer from prison (transfer for treatment direction)
o Hospital direction

Question 76

What mental health legislation is there?

Answer 76

o Mental Health (Care & Treatment) (Scotland) Act 2003
 Opens with a set of guiding principles
 Civil – emergency/short term/compulsory treatment order (hospital or community based)
 Criminal – assessment order/treatment order/transfer for treatment direction/compulsion order +/- restriction order

Question 77

What is a mental disorder under the mental health act?

Answer 77

o	A mental disorder means any:
	Mental illness
	Personality disorder
	Learning disability
•	However they were caused or manifested
o	A person is NOT mentally disordered based purely on:
	Sexual orientation
	Sexual deviancy
	Transsexualism
	Transvestism
	Dependence on, or use of, alcohol or drugs
	Behaviour that causes, or is likely to cause, harassment, alarm or distress to any other person
	Acting as no prudent person would act

Question 78

What are the different types of orders that are used in civil psychiatric cases?

Answer 78

1. Emergency detention certificate
2. Short term detention certificate
3. compulsory treatment order

Question 79

what are the general outlines of the emergency detention certificate?

Answer 79

 Can be applied by any registered medical practitioner
 Lasts for a maximum of 72 hours
 Must be likely that the patient has a mental disorder
 Patient’s ability to make decisions about medical treatment for a mental disorder must be significantly impaired
 There must be a significant risk to health, safety or welfare, or to the safety of others
 Used when there are no alternatives to treatment in hospital which is required urgently
 Used when short term detention is impractical

• Emergency detention certificate = short-acting intervention for someone who is likely to have a mental disorder

Question 80

describe the outline of the short term detention certificate

Answer 80

 Can only be applied for by an Approved Medical Practitioner (AMP) with Mental Health Officer (MHO) consent
 The patient has a mental disorder
• This mental disorder must be significantly impairing their ability to make decisions about the provision of medical treatment
 Used when it is necessary to detain the patient in hospital for the purpose of determining what medical treatment should be given to the patient or of giving them medical treatment
 Used when there would be a significant risk to the health, safety or welfare of the patient or to the safety of any other person if the patient were not detained in hospital
 Granting of STD must be necessary

• Short-term detention certificate = intervention when someone has a mental disorder for them to be detained for up to 28 days so that treatment needed needs to be ascertained

Question 81

what is a compulsory treatment order?

Answer 81

 Granted by the Mental Health Tribunal following an application by an MHO with two supporting medical reports one of which must be from an AMP
 Must have a mental disorder
 There must be medical treatment available to prevent the mental disorder worsening or which can alleviate its effects
• …and when medical treatment cannot be provided informally
 Used when there is a significant risk to health, safety or welfare, or to the safety of others
 With significant impairment in their decision making ability

• Compulsory treatment order = intervention to provide long-term treatment to someone who has a mental disorder

Question 82

What orders can be put in place during criminal proceedings?

Answer 82

o Assessment Order (section 52D) used to assess if a patient has a mental disorder
o Treatment order (section 52M) intervention to provide treatment to someone who is awaiting trial
o Compulsion Order (section 57A) this allows someone to be sent to hospital for treatment/treated in the community rather than being sent to prison
o Restriction Order (section 59) stops the release or moving of a patient
o Hospital Direction (section 59A-C) used when a patient needs psychiatric intervention but the disorder being treated is not a substantial part of the crime they are being prosecuted for

Question 83

What mental health disposals are available to the court?

Answer 83

	If further assessment and/or treatment is required prior to a final disposal being made:
•	Assessment order
•	Treatment order
•	Committal to hospital
•	Interim compulsion order
	Final mental health disposals available are:
•	Hospital disposals:
o	Compulsion order
o	Compulsion order + restriction order
o	Hospital direction
•	Community disposals:
o	Compulsion order
o	Guardianship rder
o	Treatment as a condition of probation
o	Voluntary treatment
	In some cases, courts may impose non-mental health disposals, such as:
•	Prison sentence
•	Probation order
•	Community service order
•	Fine
•	Deferred sentence
	In some cases, offenders may be admonished

Question 84

What are the indications for antidepressants?

Answer 84

o	Unipolar and bipolar depression
o	Organic mood disorders
o	Schizoaffective disorder
o	Anxiety disorders, including:
	OCD
	Panic
	Social phobia
	PTSD
	Premenstrual dysphoric disorder
	Impulsivity associated with personality disorders

Question 85

How do you choose an antidepressant for a patient?

Answer 85

o Antidepressant efficacy is similar

 Selection is based in past history of a response, side effect profile and coexisting medical conditions

Question 86

When do you decide to switch to another agent?

Answer 86

o There is a delay, typically of 3-6 weeks after therapeutic dose is achieved before symptoms improve
o If no improvement is seen after a trial of adequate length (at least two months) and adequate does, either switch to another antidepressant or augment with another agent

Question 87

How is treatment resistant depression treated?

Answer 87

o Combination of antidepressant e.g. an SSRI or SNRI + mirtazapine
o Adjunctive treatment with Lithium
o Adjunctive treatment with an atypical antipsychotic
 Quetipaine
 Olanzapine
 Aripiprazole
o Electro-convulsive therapy

Question 88

What prophylaxis is recommended in depression?

Answer 88

o After first episode of depression
 Once an episode of depression is under control antidepressant prophylaxis should continue for 6-12 months
• Evidence: 80% relapse in five years vs 20% in those on prophylaxis
o After >2 episodes of depression
 Antidepressant prophylaxis is recommended life-long

Question 89

What are the different classes of antidepressants?

Answer 89

o Tricyclics (TCAs)
 Older style of anti-depressants
o Monoamine Oxidase Inhibitors (MAOIs)
o Selective Serotonin Reuptake Inhibitors (SSRIs)
o Serotonin/Noradrenaline Reuptake Inhibitors (SNRIs)
o Novel antidepressants

Question 90

What are the advantages and disadvantages of TCAs?

Answer 90

o Advantages
 Very effective
 Cheap
o Disadvantages
 Potentially unacceptable side-effect profile
 Lethal in overdose (even a one week supply)
 Can cause QT lengthening even at therapeutic serum level

Question 91

What are tertiary TCAs?

Answer 91

o Tertiary TCAs have a tertiary amine side chain
 These side chains are prone to cross react with other types of receptors which leads to more side effects
 They have active metabolites including desipramine and nortriptyline

Question 92

What are some side-effects caused by tertiary TCAs?

Answer 92

o	Antihistaminic
	Sedation
	Weight gain
o	Anticholinergic
	Dry mouth
	Dry eyes
	Constipation
	Memory deficits
	Potentially delirium
o	Antiadrenergic
	Orthostatic hypotension
	Sedation
	Sexual dysfunction

Question 93

What are some examples of tertiary TCAs?

Answer 93

o AMITRIPTYLINE (also used for neuropathic pain
o CLOMIPRAMINE
o Imipramine
o Doxepin

Question 94

What are secondary TCAs?

Answer 94

o Secondary TCAs are often metabolites of tertiary amines and they primarily block noradrenaline. they have similar side effects to tertiary TCAs but are generally less severe

Question 95

What are some examples of secondary TCAs?

Answer 95

o Desipramine

o Nortriptyline

Question 96

What mode of action do MAOIs have?

Answer 96

o MAOIs bind irreversibly to monoamine oxidase
 This prevents inactivation of amines such as norepinephrine, dopamine and serotonin
• This leads to increased synaptic levels

Question 97

What are the advantages and disadvantaged of MAOIs?

Answer 97

o	Advantages
	Are very effective for depression
o	Disadvantages
	Side effects
	“Cheese reaction”
	Serotonin Syndrome

Question 98

What side effects are associated with MAOIs?

Answer 98

o	Orthostatic hypotension
o	Weight gain 
o	Dry mouth
o	Sedation
o	Sexual dysfunction
o	Sleep disturbance

Question 99

What is the “cheese reaction”?

Answer 99

o Cheese reaction: the cheese reaction is the name for the hypertensive crisis which can develop when MAOIs are taken with tyramine-rich foods (e.g. cheese) or sympathomimetics

Question 100

What is serotonin syndrome?

Answer 100

o Serotonin syndrome: serotonin syndrome can develop if MAOIs are taken with medication that increases serotonin or which have sympathomimetic actions.
o Serotonin syndrome symptoms:
 Abdominal pain
 Diarrhoea
 Sweats
 Tachycardia
 Hypertension
 Myoclonus
 Irritability
 Delirium
• …can lead to hyperpyrexia, cardiovascular shock and death
o To avoid serotonin syndrome when switching from and SSRI to and MAOI you should wait two weeks
 If switching from fluoxetine you need to wait five weeks due to its long half-life

Question 101

What is the action of SSRIs?

Answer 101

o SSRIs block the presynaptic serotonin reuptake

Question 102

What are the advantages and disadvantages of SSRIs?

Answer 102

o Advantages
 Treat both anxiety and depressive symptoms
 Very little risk of cardio-toxicity in overdose
o Disadvantages
 Side effects
 Discontinuation syndrome

Question 103

What side effects are associated with SSRIs?

Answer 103

o	GI upset
o	Sexual dysfunction
o	Anxiety
o	Restlessness
o	Nervousness
o	Insomnia
o	Fatigue
o	Sedation
o	Dizziness

Question 104

What are the symptoms of discontinuation syndrome in SSRIs?

Answer 104

o Agitation
o Nausea
o Disequilibrium
o Dysphoria

Question 105

What are some SSRIs?

Answer 105

o	Paroxetine
o	Sertraline
o	Fluoxetine (Prozac)
o	Citalopram
o	Escitalopram
o	Fluvoxamine

Question 106

What are the advantages and disadvantages of paroxetine?

Answer 106

o Advantages
 Short half-life with no active metabolite – no build up
• This is particularly good if hypomania develops
 Sedating properties (take dose at night)
• Offers good initial relief from anxiety and insomnia
o Disadvantages
 Significant CYP2D6 (cytochrome, member of P450, produced by the liver, used in the metabolism of drugs)
 Sedating, weight gain, anticholinergic effects
 Likely to cause a discontinuation syndrome

Question 107

What are the advantages and disadvantages of sertraline?

Answer 107

o Advantages
 Very weak P450 interactions
 Short half-life with lower build-up of metabolites
 Less sedating compared to paroxetine
o Disadvantages
 Maximum absorption requires a full stomach
• Risk of nausea if taken on empty stomach
 Increased number of GI ADRs

Question 108

What are the advantages and disadvantages of fluoxetine (Prozac)?

Answer 108

o Advantages
 Long half-life so decreased incidence of discontinuation syndromes
• Can give one tablet to taper off, when stopping an SSRI, to prevent SSRI discontinuation syndrome
 Initially activating so may provide increased energy
o Disadvantages
 Long half-life + active metabolites → build-up
 Interactions with P450
 Initial activation may increase anxiety and insomnia
 More likely to induce mania than some other SSRIs

Question 109

What are the advantages and disadvantages of citalopram?

Answer 109

o	Advantages
	↓ inhibition of P450
	Intermediate ½ life
o	Disadvantages
	Can cause QT interval prolongation
•	Dose-dependent
o	NOT >40mg/day
	Can be sedating
	GI side effects (although less than sertraline

Question 110

What are the advantages and disadvantages of fluvoxamine?

Answer 110

o Advantages
 Shortest ½ life
 Some analgesic properties
o Disadvantages
 Shortest ½ life
 GI distress, headaches, sedation, weakness
 Strong inhibitor of cytochromes in the P450 family

Question 111

What is the mode of action of SNRIs?

Answer 111

o SNRIs inhibit both serotonin and noradrenergic reuptake like tricyclic antidepressants
 They do not have the antihistamine, antiadrenergic or anticholinergic side effects

Question 112

What are the indications for SNRI use?

Answer 112

o SNRIs are used for depression, anxiety and possible neuropathic pain

Question 113

What are some SNRIs?

Answer 113

o Venlafaxine

o Duloxetine

Question 114

What are the advantages and disadvantaged of Venlafaxine?

Answer 114

o	Advantages
	↓ drug interactions, almost no P450 activity
	Short half life
	Fast renal clearance
o	Disadvantages
	Can cause ↑ BP
•	Dose dependent
	Nausea
•	Particularly immediate release tabs
	Can have a bad discontinuation syndrome
	QT prolongation
	Sexual side effects

Question 115

What are the advantages and disadvantages of duloxetine?

Answer 115

o Advantages
 Efficacy on the physical symptoms of depression
 Far less ↑ BP than venlafaxine
o Disadvantages
 Inhibits cytochromes in the P450 family
 Active ingredient is not stable in the stomach → issue if capsule is broken
 Higher dropout rate

Question 116

What is the mechanism of action of Mirtazapine?

Answer 116

o Mirtazapine is a 5HT2 and 5HT3 receptor antagonist

Question 117

What are the advantages and disadvantages of Mirtazapine?

Answer 117

o Advantages
 Different mechanism of action → ?good augmentation for SSRIs
 Can be used as a hypnotic (at lower doses)
o Disadvantages
 ↑ serum cholesterol and triglycerides in some patients
 Very sedating at lower doses
• Can be activating at doses of ≥30mg
 Weight gain

Question 118

What is the mechanism of action of Buproprion?

Answer 118

o Buproprion likely works via reuptake inhibition of dopamine and norepinephrine

Question 119

What are the advantages and disadvantages of Buproprion?

Answer 119

o Advantages
 Good as an augmenting agent
 No weight gain, sexual side effects, sedation or cardiac interactions
 Low induction of mania
 Second line ADGD agent → co-curring diagnosis use
o Disadvantages
 ↑ seizure risk at high doses
• Should be avoided, for this reason, in patients with traumatic brain injury, bulimia and anorexia
 Does not treat anxiety
• …can cause anxiety, agitation and insomnia
 Abuse potential due to psychotic symptoms at high doses

Question 120

What are the indication for mood stabiliser use?

Answer 120

o Bipolar Affective Disorder
o Cyclothymia
o Schizo Affective disorder
o Hypermanic episodes

Question 121

What are the classes of mood stabilisers?

Answer 121

o Lithium
o Anticonvulsants
o Antipsychotics

Question 122

What are the advantages and disadvantages of Lithium?

Answer 122

o Advantages
 Only medication shown to reduce suicide rate
 Effective in long-term prophylaxis of both mania and depressive episodes in a high number of BAD patients
o Disadvantages
 Side effects
 Lithium toxicity

Question 123

What factors predict positive response to Lithium?

Answer 123

o Prior long-term response
 Or a family member with good response
o Classic pure mania
o Mania is followed by depression (as opposed to the other way round)

Question 124

What side-effects are associated with Lithium use?

Answer 124

o	GI distress = MOST COMMON
	↓appetite
	Nausea and vomiting
	Diarrhoea
o	Thyroid abnormalities: hypothyroidism
o	Non-significant leucocytosis
o	Polyuria/polydipsia
	Due to ADH antagonism
•	Can cause interstitial renal fibrosis
o	Hair loss
o	Acne
o	↓ seizure threshold
o	Cognitive slowing
o	Intention tremor

Question 125

What investigations should be carried out prior to Lithium therapy being commenced? And what should be monitored throughout?

Answer 125

o	Prior
	Baseline U&Es
	Baseline TSH
	In women: pregnancy test
o	Monitor 
	creatinine levels
	TSH

Question 126

What are the symptoms of Lithium toxicity?

Answer 126

o	Mild
	Vomiting
	Diarrhoea
	Ataxia
	Dizziness
	Slurred speech
	Nystagmus
o	Moderate
	Nausea
	Vomiting
	Anorexia
	Blurred vision
	Clonic limb movement
	Convulsions
	Delirium
	Syncope
o	Severe
	Generalised convulsions
	Oliguria
	Renal failure

Question 127

What are some causes of lithium toxicity?

Answer 127

o Taking lithium at the same time as other drugs excreted by the kidneys e.g. NSAIDs
o Dehydration
o Fever

Question 128

What are the advantages and disadvantages of valproic acid?

Answer 128

o Advantages
 As effective as Lithium in mania prophylaxis
 Better tolerated than Lithium
o Disadvantages
 Not as effect as Lithium in depression prophylaxis

Question 129

What factors predict a positive response to Valproic acid?

Answer 129

o Rapid cycling patients
o Comorbid substance issues
o Mixed patients (= patients who experience mania and depression at the same time)
o Patients with comorbid anxiety disorders

Question 130

What should be done before starting valproic acid therapy?

Answer 130

o Baseline LFTs
o Pregnancy test
o FBC
o Women should be started on a folic acid supplement

Question 131

What side effects are associated with Valproic acid use?

Answer 131

o	Thrombocytopenia
o	Platelet dysfunction
o	Nausea
o	Vomiting
o	Weight gain
o	Sedation
o	Tremor
o	↑ risk of neural tube defect
o	Hair loss

Question 132

What are the indications for carbamazepine use?

Answer 132

o Carbamazepine is a first line agent for acute mania and mania prophylaxis
o Carbamazepine is indicated for rapid cyclers and mixed patients

Question 133

What should be done before starting carbamazepine therapy is started? And what should be monitored

Answer 133

o	Before
	Baseline LFTs
	FBC
	ECG
o	Monitoring
	CBC and LFTs

Question 134

What side effects are associated with carbamazepine?

Answer 134

o	Rash (most common)
o	Nausea
o	Vomiting
o	Diarrhoea
o	Sedation
o	Dizziness
o	Ataxia
o	Confusion
o	AV conduction delays
o	Aplastic anaemia
o	Agranulocytosis
o	Water retention (vasopressin-like effect) → hyponatremia
o	Drug-drug interactions

Question 135

What are some drug-drug interactions with carbamazepine?

Answer 135

o Drugs that ↑ carbamazepine levels and/or toxicity
 Acetazolamide, cimetidine, clozapine, diltiazem, INH, fluvoxamine, erythromycin, clarithromycin, fluconazole, metronidazole, propoxyphene, verapamil
o Drugs that ↓ carbamazepine levels
 Neuroleptics, barbituates, phenytoin, TCAs
o Valproic acid can ↑/↓ carbamazepine levels
o Carbamazepine increased the metabolism of some drugs
 Oestrogen & progesterone (contraceptives), warfarin, methadone, many psychotropics, cyclosporine, theophylline

Question 136

What are the indications for Lamotrigine?

Answer 136

o The indications for Lamotrigine are similar to other anticonvulsants
 Lamotrigine is also used for neuropathic/chronic pain

Question 137

What should you do before beginning Lamotrigine therapy?

Answer 137

o Baseline LFTs

Question 138

What side effects are associated with Lamotrigine?

Answer 138

o	Nausea/vomiting
o	Sedation
o	Dizziness
o	Ataxia
o	Confusion

if there is any rash then stop immediately.

Question 139

what are some common drug-drug interactions with lamotrigine?

Answer 139

o Valproic acid doubles the concentration of Lamotrigine
o Sertaline
 

Question 140

What antipsychotics are approved in BAD? And for what types of the condition?

Answer 140

o Aripiprazole → manic, mixed, maintenance
o Risperidone → manic, mixed
o Quetiapine → manic, maintenance
o Quetiapine XR → manic, maintenance, depressed
o Olanzapine → manic, mixed, maintenance

Question 141

What are the indications for use for antipsychotics?

Answer 141

o Schizophrenia
o Schizo Affective disorder
o Bipolar Affective disorder
 For mood stabilisation and/or when psychotic features are present
o Psychotic depression
o As augmenting agent in treatment resistant anxiety disorders

Question 142

What side effects are associated with antipsychotic therapy?

Answer 142

o Tardive dyskinesia: involuntary muscle movement that may not resolve with drug discontinuation
o Neuroleptic Malignant Syndrome: characterised by severe muscle rigidity, fever, altered mental state, autonomic instability, elevated WBC, CPK and LFTs. Potentially fatal
o Extrapyramidal side effects: Acute dystonia, Parkinson syndrome, Akathisia

Question 143

How are some of the side effects of antipsychotics managed?

Answer 143

o Agents for Extrapyramidal side effects:
 Anticholinergics
• Benztropine
• Trihexyphenidyl
• Diphenhydramine
 Dopamine facilitators such as Amantadine
 Beta blockers such as propranolol
• Need to watch for anticholinergic side effects (particularly if taken with drugs with anticholinergic activity e.g. TCAs)

 

Question 144

What pathways in the brain are affected by dopamine?

Answer 144

1. mesocortical
   mesolimbic
2. nigrostriatal
3. tuberoinfundibular

Question 145

describe the mesocortical pathway

Answer 145

o Mesocortical: projects from the ventral tegmentum (brain stem) to the cerebral cortex
 this pathway is thought to be where the negative symptoms and cognitive disorders (lack of executive function) arise
 Problem here for a psychotic patient is too little dopamine

Question 146

describe the mesolimbic pathway

Answer 146

o Mesolimbic: projects from the dopaminergic cell bodies in the ventral tegmentum to the limbic system
 This pathway is where the positive symptoms come from (hallucinations, delusions and thought disorders)
 Problem here for a psychotic patient is there is too much dopamine

Question 147

describe the nigrostriatal pathway

Answer 147

o Nigrostriatal: projects from the dopaminergic cell bodies in the substantia nigra to the basal ganglia
 This pathway is involved in movement regulation
 Dopamine suppresses acetylcholine activity so dopamine hypoactivity can cause Parkinsonian movements i.e. rigidity, bradykinesia, tremors, akathisia and dystonia

Question 148

describe the tuberoinfundibular pathway

Answer 148

o Tuberoinfundibular: projects from the hypothalamus to the anterior pituitary.
 Dopamine release inhibits/regulates prolactin release so blocking this pathway predisposes the patient to hyperprolactinaemia → gynecomastia, galactorrhea, decreased libido, menstrual dysfunction, bony problems (particularly in female patients

Question 149

What is the mechanism of action of typical antipsychotics?

Answer 149

o Typical antipsychotics are D2 dopamine receptor antagonists
 High potency typical antipsychotics bind to the D2 receptor with high affinity
• This means they have a high risk of extrapyramidal side effects
o FLUPHENAZINE, HALOPERIDOL, PIMOZIDE
 Low potency typical antipsychotics have less affinity for the D2 receptors but tend to interact with non-dopaminergic receptors
• This results in more cardiotoxic and anticholinergic effects including sedation, hypotension
o CHLORPROMAZINE

Question 150

What are some examples of atypical antipsychotics?

Answer 150

o	Risperidone 
o	Olanzapine 
o	Quetiapine 
o	Aripiprazole
o	Clozapine

Question 151

What are the indications for anxiolytic therapy?

Answer 151

o Panic disorder
o Generalised anxiety disorder
o Substance-related disorders and their withdrawal
o Insomnias
o Parasomnias
o Used in anxiety disorders in combination with SSRIs or SNRIs

Question 152

What are some anxiolytics?

Answer 152

o Buspirone

o Benzodiazepines

Question 153

What are the advantages and disadvantages of Buspirone?

Answer 153

o	Advantages
	Good augmentation strategy
•	Mechanism of action is 5HT1A agonist
•	Works independently of endogenous release of serotonin
	No sedation
o	Disadvantages
	Takes around two weeks for effects
	Will not ↓ anxiety in those used to benzodiazepines

Question 154

What are benzodiazepines used to treat?

Answer 154

o Insomnia
o Parasomnias
o Anxiety disorders
o Often used for CNS depressant withdrawal protocols e.g. alcohol withdrawal

Question 155

What are the associated side effects of benzodiazepines?

Answer 155

o	Somnolence
o	Cognitive deficits
o	Amnesia
o	Disinhibition
o	Tolerance
o	Dependence

Question 156

Alcohol Fatty Liver disease is reversible - true or false?

Answer 156

true

 Most heavy drinkers will have fatty liver disease
 20% will go on to develop cirrhosis
 Disappears within 6 weeks of abstinence

o Alcoholic hepatitis can be reversed if drinking is stopped immediately

Question 157

What is the risk of cirrhosis in binge drinkers vs constant drinkers?

Answer 157

o Cirrhosis rates after 13 years:
 Binge drinkers – 7.5%
 Daily drinkers – 16.1%

Question 158

What are the criteria on the Glasgow alcoholic hepatitis score?

Answer 158

1. age
2. WCC
3. urea
4. PT ratio or INR
5. bilirubin

a score that is greater than or equal to 9 has a poor prognosis

Question 159

What is the association between alcohol and malnutrition?

Answer 159

o 60% of chronic abusers have malnutrition
 Most of their calories come from alcohol
• 7kcal/g → 1300kcal per day
• They have decreased total energy intake
o Nausea and vomiting
o Abdominal pain
o Diarrhoea
 All put them off eating

Question 160

What happens in decompensated liver disease?

Answer 160

o Decompensated liver disease is when the liver isn’t doing its job anymore
 ↑ prothrombin time → GI bleeding
 ↓processing of toxins → encephalopathy
 Ascites
o 10% of patients with cirrhosis decompensate per year
 Although the vast majority of patients with cirrhosis have a liver that works well

Question 161

Is it worth stopping drinking if you already have cirrhosis?

Answer 161

o Abstinence increases 7 year survival from 44% - 72%

Question 162

What kills people with alcoholic cirrhosis?

Answer 162

o 75% die of liver disease
o 20-25% will die of hepatocellular cancer
 Also die from varicele bleeds, spontaneous bacterial peritonitis

Question 163

• What is the treatment for a hepatoma?

Answer 163

o	Surgical resection
	Possible if it’s a small tumour, restricted to one lobe of the liver
o	Liver transplant
	One tumour <5cm
	Up to 5 tumours <3cm
o	Chemotherapy = sorafanib
o	Embolisation
o	Radiofrequency ablation

Question 164

what are some resistant complications of cirrhosis?

Answer 164

o Jaundice
o Ascites
o Coagulopathy
o Encephalopathy

Question 165

What is a safe amount to drink in men and women?

Answer 165

o Women = 14 units/week
o Men = 21 units/week
o Should not drink the week’s units in one go
 Should have some alcohol free days per week

Question 166

What are the physical effects of alcohol abuse?

Answer 166

o	Skins
	Redness over nose and cheeks
	Broken veins
	“weathered” appearance
o	Bone
	Bone marrow suppression
•	Megaloblastic anaemia due to lack of vitamin B and folate
	↓ bone density 
•	Often old rib #
o	Brain
	Fits
	Delirium tremens
•	Tremor and hallucinations; often of swarming animals
	Wernecke’s encephalopathy
•	Opthalmaplegia, nystagmus, confusion, ataxia
	Korsakoff’s
•	Loss of the ability to form new memories
o	Cardiovascular system
	↑ risk of MI and stroke
•	↑ BP and cholesterol
	Alcoholic cardiomyopathy
•	Muscles are “baggy” → ↓ efficient pump
o	Lungs/respiratory system
	Aspiration pneumonia
o	GI
	Ulcers
	Reflux
	Stomach and oesophageal cancer
	GI bleeds
•	Varicele bleeds
o	Can see caput medusa and spider veins
o	Endocrine
	↓testosterone in men
	↑ risk of diabetes
o	Nervous system
	Peripheral neuropathy
•	Ulcers
o	Falls
o	Ataxia

Question 167

How do you treat alcoholism?

Answer 167

o	Treating when they have been drinking at least 10 units/day for the past ten days
o	Acute treatment
	Diazepam and pabrinex for DTs
•	Oxazepam in end stage liver disease
	+ IV thymine (given orally in the community)
o	Chronic treatment
	Psychological
•	AA
o	Helpline, sponsor, meetings
•	Drugs Action
o	Psychological support
•	Alcohol diary and monitoring
	Pharmacological
•	Acamprosate (anti-craving)
•	Disulferom (reacts badly with alcohol – unpleasant)
•	Naltrexone (takes buzz out of drinking → fewer heavy drinking days)

Question 168

How would you treat delirium tremens?

Answer 168

o Diazepam and Pabrinex

Question 169

What tools can be used to help cut down alcohol intake?

Answer 169

o	Diary and monitor
	So they can see how much they drink
	To identify triggers
o	Alternate alcohol and soft drinks
o	Pace self i.e. drink slowly
o	Don’t buy rounds
o	Rehearse turning down drinks
 

Question 170

what si the definition of dependence

Answer 170

• Strong compulsion to take the substance
• Difficulties in controlling substance intake
• Physiological withdrawal state
• Emergence of tolerance
• Neglect of other aspects of life
• Persistent use despite clear evidence of harm

• ↑tolerance
• Withdrawals (e.g. fit, tremor, anxiety)
• Craving
• ↑salience (becoming higher in list of priorities)
• Continued harm despite clear evidence of harm
o Liver (aka physical harms)
o Lover (relationships)
o Law
o Lows (psychiatric effects → anxiety, low mood, psychosis = alcoholic hallucinosis)
o Life (job, studies, etc.)
• Narrowed repertoire (only drinking one thing)
• Loss of control (can’t stop drinking)

Question 171

what is the definition of recreational use?

Answer 171

Recreational drug use is the use of a drug (legal, controlled, or illegal) with the primary intention to alter the state of consciousness (through disruption of the CNS) in order to recreate positive emotions and feelings

Question 172

what is definition of problem use?

Answer 172

: Problem or problematic drug use tends to refer to drug use which could either be dependent or recreational. In other words, it is not necessarily the frequency of drug use which is the primary ‘problem’ but the effects that drug-taking have on the user’s life (e.g. they may experience social, financial, psychological, physical or legal problems as a result of their drug use).

Question 173

what is the definition of dependence?

Answer 173

A state in which an organism functions normally only in the presence of a drug. It manifests as a physical disturbance when the drug is removed (=withdrawal)

Question 174

what is a withdrawal state?

Answer 174

: group of symptoms of variable clustering and severity occurring on absolute or relative withdrawal of a psychoactive substance, after persistent use of that substance

Question 175

When should you suspect drug addiction?

Answer 175

o	Obvious intoxication or withdrawal
o	Convictions for crime
o	Any odd behaviour e.g. hallucinations
o	Unexplained nasal discharge
o	Burns on hands or around mouth
o	Results of injecting
	E.g. track marks, BBV
o	Drug seeking behaviour

Question 176

What are the basic management principles in drug addiction/quitting?

Answer 176

o	Full assessment
o	Establish diagnosis (level of use)
o	Motivational interviewing
o	Reassurance and explanation
o	Practical advice and harm reduction
o	Counselling/psychological input
o	Medication e.g. substitution therapy, detox

Question 177

What help and community support is there for somebody who is giving up drugs?

Answer 177

o	GP
o	Specialist
	Integrated drug service/Rehabilitation service
o	DA
	Drugs action
o	Narcotics anonymous
o	Cyrenians - housing
o	Foyer – employability, training
o	Debt counsellors/legal advice

Question 178

What are the signs of opiate intoxication?

Answer 178

o	Apathy
o	Sedation/drowsiness
o	Disinhibition
o	“slowed up”
o	Reduced attention, impaired judgement
o	Interference with personal function
o	slurred speech
o	pupillary constriction

Question 179

What CNS effects do opiates have?

Answer 179

o	Euphoria
o	Warm feeling
o	Pain relief
o	Drowsiness
o	Sedation
o	Nausea
o	Vomiting
o	Respiratory depression
o	Cough reflex depression
o	Heavy feeling
o	Convulsions
	High doses only
	Very rare with methadone

Question 180

What other effects are associated with opiate use?

Answer 180

o	Dry mouth
o	Constipation
o	Constricted pupils
o	Difficulty passing urine
o	Itching
o	Sweating
o	Constriction of airways

Question 181

What are the signs of opiate withdrawal?

Answer 181

o	Craving
o	Insomnia
o	Yawning
o	Sweating
o	Muscle pain and cramps
o	Increased salivary, nasal and lacrimal secretion
o	Dilated pupils
o	Piloerection (‘cold turkey’)

Question 182

What medication is there for opiate addiction?

Answer 182

o	Methadone
	Substitution/maintenance therapy
o	Buprenorphine
	Detox or maintenance
o	Non-opiate detox
	Lofexidine, Buscopan and Zolpidem
o	Naltrexone 
	Opiate blockers
o	Naloxone
	Opiate antagonist – “reverses” effects

Question 183

What is methadone?

Answer 183

o Liquid mixture – often green
o Opiate substitute
o Available in sugar and sugar free

Question 184

What is the average effective dose of methadone?

Answer 184

o 60-120mg daily

 Once daily dosing; usually supervised

Question 185

What are the benefits of methadone?

Answer 185

o counteracting opiate withdrawal symptoms
o ↓ ILLICIT OPIATE USE
o ↓ CRIME AND DEBT
o NOT INJECTABLE → less disease
o Stabilises/normalises mood
o ↑ PHYSICAL HEALTH, NUTRITION AND ↓ MORTALITY
o Well tolerated
o Easy to supervise
o Cheap
o Doesn’t necessarily interfere with driving or working

Question 186

What are the disadvantages of methadone?

Answer 186

1. Substitute therapy (ongoing physical dependence)
2. overdose
3. Stigma
4. Long term
5. Difficult to stop
6. Potential for abuse/diversion
7. Inconvenient (daily + supervised)
8. Ongoing contact with other users

Question 187

A middle aged man is admitted to hospital with gallstones. Part of the admission history is to screen for alcohol problems.
Name an appropriate questionnaire to screen for alcohol problems?

Answer 187

FAST

Question 188

A man is admitted to A&E after being found semi-conscious in the street. He is unkempt. And does not have any information on his person; he appears to be street homeless. In A&E he has a tonic clonic seizure which is self-limiting after 3 minutes. The man is postictal for a short time but soon becomes restless, tremulous and sweaty. His speech is rambling, and he complains about the bed sheets being filthy and ‘filled with mites’. He is tachycardic with a blood pressure of 186/114 mmHg.

1. What is the most likely diagnosis?
2. You order a full set of bloods on this man. Which of the following results would be most indicative of the underlying cause of his delirium?

Answer 188

1. Delirium tremens

2. Low serum vitamin B12

Question 189

Amnesia may be a form of dissociation.

true or false?

Answer 189

true

Question 190

medical treatment for anorexia nervosa is with antipsychotic (olanzapine) and antidepressant therapy (fluoxetine). aside from medical treatment, name 4 other methods of treatment of anorexia nervosa

Answer 190

1. CBT for eating disorder
2. IPT
3. socialised family work - particularly for younger children
4. mantra (20 session)
5. re-nutrition - especially in younger children for growth and development
6. specialist supportive clinical management
7. sympathetic awareness (patient is scared and upset so no accusations)

Question 191

A rather thin young student presents to her GP complaining that she has not had a menstrual period for over a year although she is not taking the contraceptive pill. She has been ‘very stressed’ by her university course but is still doing well academically, and belongs to the University triathlon club. She becomes tearful when the GP suggests weighing her, and insists she eats very well, indeed she finds herself often eating far more than she intended and is worried that she may gain weight. Blood results are normal apart from a low potassium value, low total white count and mild neutropenia and slightly low TSH.

what is the most likely diagnosis?

Answer 191

anorexia nervosa

binge-purge subtype

Question 192

A 23 y/o man experiences irritability, grandiose delusions as a reduced need for sleep. He has previously been in a psychiatric hospital treated for depression. Which is the most likely diagnosis

Answer 192

Bipolar affective disorder (BAD)

Question 193

A 79 y/o man who has had 2 hospital admissions for depression in the past is brought to the GP by his daughter. She is concerned that he is spending lots of money, has a reduced need to sleep, is full of energy and wants to run a marathon

what is the most likely diagnosis?

Answer 193

bipolar Affective disorder

Question 194

A 45 y/o man is assessed in the outpatient department. He has an intense interest in rare woods and has a very rigid timetable which he sticks to each day. He is upset that the doctor assessing him was 10 minutes late. What is the most likely diagnosis?

Answer 194

Autistic Spectrum Disorder

Question 195

what are the management options for autism spectrum disordeR?

Answer 195

1. early speech therapy
2. behavioural interventions
3. social skills training
4. risperidone

autism diagnostic observation schedule will be helpful for diagnosis

Question 196

A 39 y/o woman presents with a complaint that she is fearful that something bad may happen to her. This fear occurs wherever she goes and she cannot describe what might happen. She also complains of pains in her chest, a tremor and sweating at times. What is the most likely diagnosis?

Answer 196

Generalised anxiety disorder (GAD)

Question 197

constipation is a typical presentation of anxiety, true or false?

Answer 197

false

Question 198

The presence of major depression excludes a diagnosis of GAD - true or false?

Answer 198

false

Question 199

Cognitive theories propose that anxiety is the result of distorted thinking, such as catastrophizing and labelling, true or false?

Answer 199

true

Question 200

An 80 year old man is admitted with weight loss, poor motivation, social isolation, lack of interest in bowling which he previously did regularly, suicidal ideation and tearfulness. Which of the following is the most likely diagnosis?

Answer 200

Depression

Question 201

A 38 year old woman has consulted her GP and a diagnosis of moderate depression has been made. Which of the following would be an appropriate first-line treatment?

Answer 201

Sertraline

Question 202

Which of the following psychological treatments is recommended in the first line treatment of depression?

Answer 202

Cognitive Behaviour Therapy

Question 203

You are a GP and have diagnosed a 27 y/o lady with depression. You are confident that she does not require to be treated in hospital and wish to start her on treatment. Which of the following would be appropriate 1st line treatment?

Answer 203

SSRI

Question 204

A 34 y/o man develops depression and suffers the inability to experience pleasure but can experience other emotions. What is the correct term for this?

Answer 204

Anhedonia

Question 205

A 68 y/o woman has been diagnosed with severe depression. One of the symptoms is that she believes her bowels are rotting. What is the correct term for this?

Answer 205

Nihilistic delusion

Question 206

A 24 y/o woman presents who has a 1 month history of low mood, early morning awakening, irritability, reduced appetite and some suicidal thoughts. She also feels guilty that she feels too tired to take her 2 y/o daughter to nursery. Which is the most likely diagnosis?

Answer 206

Depression

Question 207

You are a psychiatrist treating a 34 y/o woman with depression. You are confident of the diagnosis. You have already tried 2 antidepressants and the 2nd has had only partial effect. Her mood has lifted slightly but she complains of poor sleep, lack of energy and motivation and poor appetite. Which of the following is the most appropriate next step?

Answer 207

add lithium

Question 208

Hyperphagia is a core symptom of depression according to ICD-10. true or false?

Answer 208

false

Question 209

Which of the following medications is most likely to be associated with an organic depressive disorder?

Answer 209

Prednisolone

Question 210

what is the most common psychiatric symptom following a stroke?

Answer 210

Depressive

Question 211

A 35 y/o woman complains of low mood after the death of her husband in a car accident. She does not speak and remains immobile for long periods. What is the most likely diagnosis?

Answer 211

Depressive stupor

Question 212

A 45 y/o female has had persistent mild depressive features since her late teens. She sometimes experiences loss of energy and tearfulness. She believes her low mood began after she was abused by her stepfather as a teenager. She has no other symptoms. What is the most likely diagnosis?

Answer 212

Dysthymia (chronic low grade mood disorder)

Question 213

What is the most likely condition causing a depressive episode in a 76 y/o man with a history of smoking and hypertension?

Answer 213

stroke

Question 214

A 35 y/o female visits her GP complaining of low mood and weight loss. On questioning she also experiences fatigue which is exacerbated by pain in her legs. Blood tests reveal high potassium. Which of the following is most likely to cause her depression?

Answer 214

Addisons disease

Question 215

A 43 y/o female visits her GP complaining of a 4-week history of fever, fatigue, low mood and lower back pain. She had visited China in the previous month and mentioned she was drinking plenty of goat’s milk as this was the only type of milk available. What is the most likely infective cause?

Answer 215

Brucellosis

Question 216

A 35 y/o woman has had a low mood for 2 months associated with fever, fatigue and joint pain. She has a rash on her face which gets worse with exposure to the sun. What is the most likely cause of her low mood?

Answer 216

Systemic Lupus erythematosus

Question 217

Methyl dopa is known to have depression as a side effect - true or false?

Answer 217

true

Question 218

A 23 y/o man is assessed by his GP. He has a severe dermatological condition affecting his hands which is caused by his washing them 13 times before he leaves his house. What is the most likely diagnosis?

Answer 218

Obsessive compulsive disorder (OCD)

Question 219

OCD affects women and men equally true or false?

Answer 219

true

Question 220

Antidepressants do not have a role in the management of OCD. true or false?

Answer 220

false

use SSRI - fluoxetine and TCA - clomipramine

Question 221

constipation is not a typical feature of anxiety true or falsE?

Answer 221

true

Question 222

A 46 y/o woman is referred to 2ndary psychiatric services by her GP. Over the last 6 months she has suffered multiple losses, including the death of her sister and close friend. She lives alone with few social contacts. She has become extremely withdrawn, and is leaving the house less, stating that she gets ‘terrified that I won’t be able to get back to my house’. She reports that when she does go out, she feels breathless, sweaty and like ‘she might faint and make a fool out of myself’. What is the most likely diagnosis?

Answer 222

Agoraphobia

Question 223

A woman is diagnosed with agoraphobia. She is willing to try any form of treatment as her condition is very disabling. would you give lorazepam as first line treatment for agoraphobia?

Answer 223

no

Question 224

Men are less likely to report symptoms of social phobia than women - true or false?

Answer 224

true

Question 225

Cognitive theories propose that anxiety is the result of distorted thinking, such as catastrophizing and labelling
- true or false?

Answer 225

true

Question 226

The behavior must affect the ability to control impulse is needed for the diagnosis of personality disorder - true or false?

Answer 226

false

Question 227

It is now generally accepted that personality can be described by 3 factors - true or false?

Answer 227

false

it is 5.

Question 228

A 22 y/o woman with a diagnosis of borderline personality disorder attends A&E after saying she has taken an overdose of paracetamol following an argument with her mother. She is an outpatient at the local personality disorder service where she has a key worker. This is her fourth attendance in A&E for similar reasons in the last 6 weeks. A full assessment reveals no evidence of depression. Her blood results reveal low levels of paracetamol. She does not want to die but cannot say she will not try and harm herself again. What would the most appropriate management be?

Answer 228

Discharge from A&E with follow-up from her key worker

Question 229

A 29 y/o man is arrested for aggravated assault on a former girlfriend. It is his 9th offence of a similar nature. The court asks for a psychiatric opinion. He is noted to be emotionally cold with an extremely reduced tolerance to frustration. He feels no remorse for his actions, blaming his girlfriend for ‘putting it about’. What is the most likely diagnosis

Answer 229

Antisocial personality disorder

Question 230

A 19 yo man is referred to the local psychiatric community team as his new GP is worried he is schizophrenic. The letter states that he is ‘extremely odd and does not seem to have an emotional response to anything’. On assessment, he states he has only come to understand the psychiatric care pathway; a little more but does not feel he has any problems. He seems aloof and disdainful of the psychiatrist. He appears to have few hobbies except for inventing his own mathematical equations. What is the most likely diagnosis?

Answer 230

Schizoid personality disorder

Question 231

A soldier who has recently returned from active combat attends his GP as he has frequent nightmares, startles easily, tries to avoid his army friends and anything to do with his job and is always on edge. What is the likely diagnosis?

Answer 231

Post Traumatic Stress Disorder

Question 232

A 42 y/o man sees his GP after witnessing a horrific motorway pile-up. For the last 6 weeks he has been experiencing recurrent and intrusive images of the event where he relives what happened, both at night and during the day. At night he is also having vivid nightmares about the crash which is now stopping him from going to sleep. He has not driven his car since, although he himself was not involved in the crash. Every time a car starts he jumps and becomes extremely upset. His mood is low and he feels disconnected from his wife and children and he has been thinking about killing himself.

1. does this patient have night terrors?
2. What is the most likely diagnosis in the case?

Answer 232

1. no
2. PTSD
   `

Question 233

A 42 y/o man is involved in a serious road traffic accident caused by a drunk driver. He is hospitalised for several weeks. Following discharge, friends and family notice that he is not going out, has become withdrawn and appears withdraw and appears frightened and anxious all the time. He reluctantly agrees to see his GP. in PTSD, do patients usually present with a diminished startle response?

Answer 233

no

Question 234

A woman presents hearing the national anthem playing when there is no music in the house. Which of the following symptoms is this an example of?

Answer 234

Auditory hallucination

Question 235

An elderly man has been admitted to hospital with acute onset disorientation, visual hallucinations and agitation. He has no psychiatric history and lives alone and requires no support. What is the most likely diagnosis?

Answer 235

Delirium

Question 236

A 22 y/o man with no previous psychiatric illness sees a street lamp flicker and suddenly knows that he is the next Scottish ambassador to Wales. What is the correct term for this?

Answer 236

delusional perception

Question 237

A man is admitted to A&E after being found semi-conscious in the street. He is unkempt. And does not have any information on his person; he appears to be street homeless. In A&E he has a tonic clonic seizure which is self-limiting after 3 minutes. The man is postictal for a short time but soon becomes restless, tremulous and sweaty. His speech is rambling, and he complains about the bed sheets being filthy and ‘filled with mites’. He is tachycardic with a blood pressure of 186/114 mmHg. What is the most likely diagnosis?

Answer 237

delirium tremens

dont forget that the cause of delirium is a low serum vitamin B12

Question 238

A 73 y/o woman is admitted to hospital with an infective exacerbation of chronic obstructive pulmonary disease (COPD). Apart from COPD and hypertension she has no other medical problems. On the 3rd day of her admission, she becomes acutely confused. During the night she is awake, shouting constantly for her husband, claiming that the nurses are prison guards and that they are keeping her against her will. She is slightly calmer the day after. You are the FY1 on call and are asked to come and see her over the weekend as the nurses are worried it will happen again at night. What should your initial management be

Answer 238

prescribe nothing at this stage

Question 239

A 24 y/o student presents with a 3-month history of social withdrawal and low mood. She is difficult to interview because she talks about random themes and has difficulty answering questions. She has vague paranoid ideation. She is childish and pulls faces at you during the interview. The most likely diagnosis is?

Answer 239

Hebephrenic (disorganised) schizophrenia

Question 240

What is the lifetime prevalence of schizophrenia in the UK

Answer 240

0.4 per 100

Question 241

) A 28 y/o woman presents in the GP surgery. She is over-talkative and over-familiar with you. It is difficult to get a full history, but it seems for the last 4 weeks she has been elated and experiencing voices telling her that her mother was a descendent of the VIrgin Mary and that she is a female ‘second coming’. This was the result of an experiment by the Nazi party who genetically engineered her grandparents. She believes that remnants of the Nazi party are now controlling her arms and legs, which results in her alternately trying to hug you and then kicking out at the desk. What is the most likely diagnosis?

Answer 241

Schizoaffective disorder

Question 242

An 8 y/o boy is referred with behavioural problems to the child psychiatry department. He is always active at home and moves from task to task. He finds it difficult to concentrate to read or to watch TV. He often puts himself into dangerous situations like climbing onto high roofs. His performance at school is poor where he is distractible and causes distractions to others. What is the most likely diagnosis?

Answer 242

ADHD

Question 243

what is buprenorphine?

Answer 243

an opiate based treatment for opiate addiction

Question 244

when is buprenorphine used?

Answer 244

MILD opiate addiction and for detox

it is administered in tablet form that dissolves under the tongue (2-24mgs)

Question 245

what si suboxone?

Answer 245

partial opiate with a high affinty for the receptor and pushes other opiates off the brain - apart from naltrexone

Question 246

name some advantages and disadvantages of suboxone

Answer 246

1. blocks additional opiates if used on top and has similar effects to methadone
2. safe - less likely to cause sedation and overdose
3. risk of sending people into withdrawal
4. more expensive than methadone
5. can make giving analgesia difficult

Question 247

what is naltrexone?

Answer 247

a blocker that is used as a deterrent tablet. it is an opiate with very high affinity for the receptor./

Question 248

how does naltrexone work?

Answer 248

displaces existing opiates and doesnt produce effects (just sits there)

protects from heroin when heroin is used on top and has implications for analgesia

it can help maintain abstinence

Question 249

When are drugs such as Lofexidine, Buscopan and Zolpidem used?

Answer 249

they are useful in MILD opiate addiction/withdrawal.

they are also useful in short-term non-opiate treatment regime for symptomatic relief only.

Question 250

what is the mechanism of action of lofexidine?

Answer 250

it is an alpha-adrenergic agonist that blocks noradrenaline and decreases sympathetic tone.

it will counteract opiate withdrawal/craving and may cause hypotension

Question 251

what is the mechanism of action of buscopan?

Answer 251

it is an antimuscarinic that relaxes smooth muscle.

it is indicated to stop stomach cramps

Question 252

what is the mechanism of action of Zolpidem?

Answer 252

it is a non-benzodiazepine hypnotic and helps people to sleep

Question 253

what is nalxone?

Answer 253

it is an opioid antidote that is administered IM.

It is used to reverse opioid overdose
it will temporarily reverse opioid overdose an is beneficial because it cannot cause overdose.

Question 254

describe the management of cocaine and cannabis addiction

Answer 254

1. counselling/psychological work

unfortunately there is no methadone equivalent for cocaine.

Question 255

how do you manage benzodiazepine addiction

Answer 255

depends on use and motivation. decrease the diazepam regimen may be appropriate.

counselling and motivational work.

Question 256

what is the management for legal high addiction?

Answer 256

1. counselling
2. harm reduction
3. depends on substance - not usually a ‘medical equivalent’, may give some symptomatic treatment