Psychiatry Flashcards
1
Q
What is meant by the Bio-Psycho-Social model?
A
Biological - what is the underlying medical issue?
Psychological - is any extra support needed?
Social - Living situation? Financial issues?
2
Q
What is the Crisis Resolution and Home Treatment Team (CRHTT)?
A
A team consisting of a psychiatrist, junior doctor, registered mental health nurse, HCA and OT who can see a patient 2-3 times per day and assess mental state and need for admission, give medication etc.
You can discharge people from hospitals with the follow up of the CRHTT
3
Q
What are section 135 and 136 orders?
A
The police have the right to take you to a place of safety for assessment by a mental health team - a section 136 allows the police to do this if you are outside your home, while a section 135 is more complicated, but basically allows them to do it when you’re inside your home
4
Q
What is the Early Intervention Service (EIS)?
A
A community service with an MDT (similar to CRHTT) who help young people (<35y/o) with their first episode of psychosis
5
Q
How is the Community Mental Health Team (CMHT) different to the CRHTT?
A
They look after patients in the long term
6
Q
What is IAPT?
A
Improving Access to Psychological Therapies - GP surgeries can refer you for therapies such as CBT or counselling under IAPT. You can also self-refer but the waiting list is often very long
7
Q
What is the MMSE from start to finish?
A
30-point test - 1 point for each correct answer: ORIENTATION - Year - Season - Month - Date - Time - Country - Town - District - Hospital - Ward/Floor
REGISTRATION:
Name 3 objects and ask the patient to repeat them (out of 3 marks).
ATTENTION and CALCULATION:
Ask the patient to subtract 7 from 100, then repeat from result (100, 93, 86, 79, 72) - do this 5 times.
Alternative - Spell ‘WORLD’ backwards.
RECALL:
Ask for the names of the 3 objects mentioned earlier (out of 3 marks).
LANGUAGE:
Name two objects (out of 2 marks)
Repeat the sentence ‘no ifs, ands, or buts’ (/1)
Give a 3 stage command (place right index finger on nose and then left ear) (/3)
Ask patient to read and obey a written command (‘close your eyes’) (/1)
Ask patient to write a sentence - score 1 mark if it is sensible and has a subject and a verb (/1)
COPYING:
Ask the patient to copy and image of a pair of intersecting pentagons (/1)
MMSE Scoring:
24-30 No cognitive impairment
18-23 Mild cognitive impairment
0-17 Severe cognitive impairment
8
Q
What is the AMTS from start to finish?
A
10 point test:
- Age?
- Time (nearest hour)?
3a. Give an address to recall at the end. - Year?
- Name of location?
- Identification of 2 persons (e.g. doctor, nurse).
- DOB?
- Year of the First World War?
- Name of the present monarch?
- Count back from 20 to 1.
3b. Recall address.
A score of 6 or less suggests delirium or dementia - further tests are necessary to confirm.
9
Q
What are the ICD-10 and DSM-IV?
A
Useful literature for mental health diseases - ICD-10 chapter 5 gives all mental health diseases and DSM-IV is all about mental health diseases.
10
Q
What is the order of the diagnostic hierarchy of mental health?
A
Organic (head injury, drugs etc.) Psychosis Affective (mood) Neurosis (anxiety) Personality No mental illness
11
Q
Psychosis:
Definition
Key symptoms (3)
Causes
A
Definition: Loss of connection with reality
Key Symptoms:
Hallucinations - no external stimulus but you have a perception of any modality
Illusions - external stimulus misinterpreted (e.g. thinking a shadow is a person)
Delusions - false unshakeable beliefs (can be negative/nihilistic in context of depression, or grandiose in context of mania)
Causes:
Organic (drug-induced, delirium, dementia)
Schizophrenia
Delusional disorders
Affective disorders (depressive psychosis or manic psychosis)
12
Q
In what circumstances do we need to follow the Deprivation of Liberty Safeguards?
A
DoLS are used when patients who need admission but have no capacity are accepting of that admission - they are series of safeguards which tell hospitals and care homes the process they must follow to ensure that their actions are in the patient’s best interests and they’re kept safe
13
Q
For how long can someone be admitted under a section 135?
A
Up to 72 hours for MHA assessment
14
Q
For how long can someone be admitted under a section 136?
A
Up to 24 hours for MHA assessment
15
Q
Which 5 parties should be present in order for an MHA assessment to be performed?
A
Patient
AMHP
Medical recommendation 1 (S12 approved doctor)
Medical recommendation 2 (any fully registered practitioner - preferably patient’s GP)
Nearest relative (should be consulted, and for a section 3 they must agree)
16
Q
Who has the final decision on sectioning a patient?
A
The AMHP
17
Q
What are the 3 criteria for detention under the MHA?
A
Person is suffering from a mental disorder
AND
It is of a nature or degree to warrant detention in hospital for assessment or assessment followed by treatment
AND
Person ought to be detained in the interests of their own health or safety or with a view to the protection of others
18
Q
What are the types of section?
A
Civil (all unrestricted) - Section 2 or 3
Section 5(2) or 5(4)
Section 117 or 17
CTO
Criminal, unrestricted - Section 37
Criminal, restricted - Section 37/41 or Section 47/49
19
Q
Section 2:
What power does it provide?
What can it be used for? (3)
What are the legal rights related to it? (2)
Which section can be used to provide leave from the ward?
A
Power: To detain and treat a person in hospital for up to 28 days.
Uses:
Admit a patient from the community
Prevent a voluntary patient from leaving hospital
Following short-term section (135(1), 136, 5(2), 4)
Legal rights:
Patient can appeal to MH review tribunal
Right to independent mental health advocate
Section 17 can provide leave from the ward.
20
Q
Section 3:
How long does it last?
What conditions are required to detain someone under section 3? (2)
A
Lasts 6 months
Must show that treatment cannot be provided unless the patient is detained
Must be able to provide the appropriate medical treatment
21
Q
Section 5(2):
Who can detain people under section 5(2)? (2)
How long does it last?
What is its purpose?
A
Who? Consultant psychiatrist or nominated deputy.
How long? 72 hours
Purpose: Detain a patient receiving care for a physical condition on a general ward to be assessed for a mental disorder.
NOTE 1: It cannot be used to authorise treatment (only authorises assessment).
NOTE 2: Cannot be used in A&E or outpatients.
22
Q
What are the sections in a Mental State Examination (MSE)?
A
Appearance/Behaviour Speech Mood Thought Perception Cognition Insight
23
Q
What is meant by each of the following: Pressure of speech Poverty of speech Thought block Circumstantial speech Flight of ideas Derailment Perseveration
A
Pressure of speech - speaking quickly
Poverty of speech - speaking slowly with little content
Thought block - sudden halt in speech with loss of content
Circumstantial speech - going on a massive tangent
Flight of ideas - sudden changes in thoughts
Derailment (aka loosening of associations or knight’s more thinking) - no obvious link between thoughts
Perseveration - answers to questions are repeated inappropriately
24
Q
List the types of delusions (10)
A
Grandiose - exaggerated beliefs of being special or important
Persecutory (paranoid) - beliefs that others are trying to persecute or cause harm
Nihilistic - beliefs regarding the absence of something vitally important (e.g. patient is dead or their organs are rotting)
Delusions of reference - beliefs that ordinary objects, events or other peoples’ actions have a special meaning or significance to the patient
Delusions of control - beliefs that outside forces may control the patient in some way
Passivity - belief that the movement, sensation, emotion or impulse are controlled by an outside force (e.g. someone has a remote control for the patient’s actions)
Delusions of thought interference - occur against the patient’s will and feel like an invasion of privacy (these include thought withdrawal, thought insertion and thought broadcasting)
Amorous (erotomatic) - belief that someone is in love with the patient (more common in women)
Delusions of guilt - belief of having committed an awful sin or crime
Hypochondriacal - belief that the patient has an illness
25
What are overvalued ideas?
Reasonable ideas pursued beyond the bounds of reason e.g. thinking that the neighbours' front garden is unsightly due to the gnomes, and then quitting work and taking the neighbour to court to destroy the gnomes with a hammer
26
What condition are thought echo and running commentary associated with?
Schizophrenia
Thought echo is a hallucination where the patient's thoughts are heard aloud
Running commentary is a hallucination where there is a running commentary of the patient's actions
27
What is the difference between depersonalisation and derealisation?
```
Depersonalisation = person feeling detached/numb
Derealisation = world feeling false (like a film set)
```
28
What is the Holmes-Rate Social Readjustment Scale?
A scale that ranks difficult life events (death of a spouse is hardest etc.). Says that the more stressful life events someone has been though, the more likely they are to develop depression.
29
What are the 3 corners of Beck's Cognitive Triad?
1. Negative views about the world
2. Negative views about the future
3. Negative views about oneself
This model is the basis of CBT.
30
What do psychoanalytical theories of depression say?
Early experience, particularly the quality of early relationships, determines the risk of later depression
31
Explain the monoamine hypothesis of depression.
Suggests that depression results from a deficiency in brain monoamine neurotransmitters:
Noradrenaline (affects mood and energy)
Serotonin (affects sleep, appetite, memory and mood)
Dopamine (affects psychomotor activity)
32
How might endocrine abnormalities (in theory) cause depression?
Cortisol elevation during stressful life events can damage the hippocampus
33
What are the 4 subtypes of depression?
Seasonal affective disorder - low mood in winter, overeating, oversleeping
Atypical depression - no seasonal variation but shows reversed biological symptoms (overeating/oversleeping) and may retain mood reactivity
Agitated depression - depression with psychomotor agitation (instead of retardation) such as restlessness and pacing
Depressive stupor - when psychomotor retardation is so profound that the person grinds to a halt, they become mute and stop eating, drinking or moving
34
In CBT, patients are taught to challenge their negative automatic thoughts (NATs) - which 2 common thinking errors are they taught about?
Generalisation - 'I always mess everything up'
| Minimisation - 'I only passed the exam by chance. I'm not good enough'
35
What is transference?
Seen in psychodynamic psychotherapy, it is where the feelings a person has about their past relationships are unconsciously redirected or transferred onto the therapist - e.g. 'They will reject me'
36
What are the 4 key themes explored in interpersonal therapy?
Unresolved loss
Psychosocial transitions
Relationship conflict
Social skills deficit
37
How long should pharmacological treatment continue in a patient with depression?
Until 6 months after the patient is no longer depressed, in order to prevent relapse
38
Name 6 SSRIs, and list the side-effects of SSRIs.
Fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, escitalopram
Nausea/Vomiting, appetite/weight change, blurred vision, anxiety/agitation, insomnia/tremor/dizziness, headache, sweating
39
Name 2 SNRIs, and list the side-effects of SNRIs.
Venlafaxine, duloxetine
Constipation, hypertension and hypercholesterolaemia
+
The side-effects of SSRIs (Nausea/Vomiting, appetite/weight change, blurred vision, anxiety/agitation, insomnia/tremor/dizziness, headache, sweating)
40
Name 5 TCAs, and list the side-effects of TCAs.
Amitriptyline, clomipramine, imipramine, lofepramine, dosulepin
Tachycardia, arrhythmias, dry mouth, blurred vision, constipation, urinary retention, postural hypotension, sedation, nausea, weight gain
41
Antidepressants of different classes can have dangerous interactions, so always check carefully before changing. Some can be cross-tapered but others need a drug-free wash out period. Giving multiple antidepressants can lead to serotonin syndrome - what is serotonin syndrome?
Accumulation of excess serotonin leading to agitation, sweating, myoclonus, confusion and seizures. It can be life-threatening.
42
How do we define treatment resistance in the use of antidepressant drugs?
Failure to respond to 2 adequate trials of different classes of antidepressants at adequate doses and for a period of 6-8 weeks.
43
What drugs can be given as 'augmentation strategies' alongside antidepressants?
Lithium
Thyroxine
Buspirone (anxiolytic that has no antidepressant effect alone but has a synergistic effect with SSRIs)
44
Name 2 non-drug options for the treatment of depression (therapies such as CBT not included).
Electroconvulsive therapy (ECT) - electrodes used to produce generalised tonic-clonic seizures whilst the patient is anaesthetised. Some patients have a degree of memory loss afterwards.
Light therapy - can be used in seasonal affective disorder (compensates for fewer hours of daylight in winter).
45
What is the prognosis for depression?
50% will have at least one more episode
Episodes last on average 8-9 months (reduced to 2-3 months with treatment)
Psychotic depression has a poorer prognosis but a better response to ECT
46
What is the difference between mania and hypomania?
To diagnose a manic episode, symptoms should last at least 1 week and prevent work and ordinary social activities - less severe symptoms which don't entirely disrupt a patient's ability to function are termed hypomania (hypomanic periods can lead to high productivity).
47
What are the core symptoms of mania?
Mood, energy and enjoyment are elevated (raised mood can range from uncontrollable excitement to irritability/aggression)
NOTE: Mood can be labile.
48
What are the cognitive symptoms of mania? (5)
Inflated self-esteem
Hopefulness (world seems full of opportunity)
Racing thoughts
Poor concentration (although patient may feel they are thinking more clearly than ever)
Flight of ideas (topics changing rapidly)
49
What are the biological symptoms of mania? (3)
Reduced sleep
Voracious appetites for food and sex
Reckless/Disinhibited behaviour (risky sexual behaviour, drugs/alcohol, driving recklessly, gambling/spending excessively)
50
What are the psychotic symptoms of mania? (3)
Grandiose delusions
Persecutory delusions
Auditory hallucinations
51
Complete the following:
| A diagnosis of bipolar affective disorder (BPAD) can be made when...
...a patient has suffered a manic episode and any other affective episode (depressed, hypomanic, mixed).
52
What are the 3 subtypes of bipolar affective disorder (BPAD)?
Type 1 - manic episodes interspersed with depressive episodes
Type 2 - mainly recurrent depressive episodes, with less prominent hypomanic episodes
Rapid Cycling BPAD - four or more affective episodes in a year, more common in women, may respond better to sodium valproate
53
What is cyclothymia?
Persistent mood instability with many episodes of mild low mood and mild elation - none of them are severe or prolonged enough to meet criteria for mild depression or hypomania.
54
What are the 3 main mood stabilisers used in mania/BPAD? What other drugs can be used?
Lithium
Sodium valproate
Carbamazepine
Other drugs:
Antipsychotics (usually atypical e.g. olanzapine, risperidone, quetiapine due to fewer side-effects)
Anticonvulsants e.g. lamotrigine (good for prophylaxis in BPAD Type 2
55
What is the therapeutic range for lithium? At what point does it become toxic?
Therapeutic range = 0.6-1.0mmol/L
Becomes toxic from 1.2mmol/L
Because of this, lithium levels should be checked 1 week after starting or changing dose and monitored weekly until a steady therapeutic level is achieved. They should be monitored every 3 months from then on.
56
Other than lithium levels, what should be monitored in patients taking lithium?
U&Es and TFTs (every 3-6 months) as lithium can cause renal impairment and hypothyroidism.
57
Give the symptoms (7), triggers (3) and management (2) of lithium toxicity.
Symptoms: GI disturbance, sluggishness, giddiness, ataxia, gross tremor, fits, renal failure
Triggers: Salt balance changes (e.g. dehydration, D&V), drugs interfering with lithium (e.g. diuretics), accidental or deliberate overdose
Management: Stop lithium, transfer for medical care (rehydration, osmotic diuresis)
58
Which drug is used to treat acute mania?
Valproate (given as sodium valproate due to reduced side-effects)
Also used for prophylaxis in BPAD
59
Which drug is 2nd line for BPAD prophylaxis?
Carbamazepine - anticonvulsant, induces liver enzymes, close monitoring required due to toxicity, check drug interactions before prescribing
60
What are the risks of using mood stabilisers in pregnancy?
They are teratogenic so risk of harm should be weighed against risk of manic relapse.
Lithium - Ebstein's anomaly
Volproate and carbamazepine - Spina bifida
NOTE: Women of childbearing age should be given contraceptive advice and prescribed folate supplements if using valproate.
61
What is the management of acute mania?
Stop all medications that may be responsible (e.g. antidepressants)
Monitor food and fluid intake to prevent dehydration
If treatment free:
Give an antipsychotic or mood stabiliser (a short course of benzodiazepines is often added for sedation because sleep deprivation can exacerbate mania)
If already on treatment:
Optimise medication
Check compliance
Adjust doses
Consider addition of antipsychotic or mood stabiliser, and benzodaizepines
ECT can be used if patients are unresponsive to medication
62
What is the prognosis for bipolar affective disorder?
15% of people with BPAD will commit suicide, but lithium reduces this to same as the general population
63
Give 4 social causes of suicide.
```
Life events and stress
Social class (I and V are more likely to commit suicide)
Social isolation (more common if isolated, divorced, widowed, single, unemployed or living alone)
Occupation (higher rates in v its, pharmacists, dentists, farmers and doctors)
```
64
What percentage of people who commit suicide have previously self-harmed?
Up to 60%
65
What percentage of people who commit suicide are depressed?
Up to 80%
66
What percentage of people who commit suicide have a personality disorder?
Up to 50%
67
Name a charity for the family of suicide victims.
Survivors of bereavement by suicide (SOBS)
68
List 4 suicide prevention strategies.
Limiting pack sizes of paracetamol
Installing barriers at suicide hotspots
Providing free telephone services (e.g. Samaritans)
Catalytic converters on cars
69
Which age group is self-harm most common in?
Children and adolescents
70
What is the management of self-harm?
```
Physical treatment (of overdoses, lacerations or burns)
Risk assessment (thoughts of repeating, thoughts of hurting others, thoughts of being hurt by others etc.)
```
NOTE: If the patient is insistent on leaving you must assess their capacity
Immediate interventions:
Admission to psychiatric ward (if high risk and lacking capacity)
Possible to manage at home (depending on circumstance)
Make a plan to deal with future suicidal ideation or thoughts of self-harm (e.g. who can they tell/how can they get help?)
Follow-up interventions:
Follow-up within 1 week of self-harm or discharge
Could be done by community mental health team, outpatient clinic, GP or counsellor
Treat underlying conditions e.g. depression
Offer psychological therapies (CBT, mentalisation-based treatment, transference-focussed therapy)
71
What percentage of suicides occur within 3 months of discharge from psychiatric wards?
30%
72
What is the lifetime risk of developing schizophrenia?
1% (which increases to 10% in people with a first degree relative with schizophrenia)
73
Which obstetric complications increase the likelihood of the child going on to develop schizophrenia? (5)
```
Maternal prenatal malnutrition
Viral infections
Pre-eclampsia
Low birth weight
Emergency C-section
```
NOTE: May reflect underlying genetic abnormalities or may be linked to hypoxic brain damage.
74
Which drugs can lead to psychotic symptoms, predisposing to schizophrenia? (4)
Cannabis (especially skunk)
Amphetamines
Cocaine
LSD
75
Which genetic mutation causes highest risk of developing schizophrenia in cannabis users?
Val-Val mutation in the COMT gene.
76
Which ethnicity is schizophrenia most common in?
Afro-Caribbean
77
Premorbid schizoid personality precedes schizophrenia in what percentage of cases?
25%
78
What theories exist to explain schizophrenia?
Neurodevelopmental - initial brain abnormalities (genetic or due to early brain damage), or maturation of the brain may lead to functional/connectivity abnormalities
Neurotransmitter - Dopamine hypothesis (schizophrenia is a result of dopamine overactivity in certain brain area) - positive symptoms (hallucinations/delusions) are caused by excess dopamine in mesolimbic tracts while negative symptoms (apathy/social withdrawal) are caused by dopamine deficiency in the mesocortiyal tracts
- -> Evidence for this theory is 2 fold:
1. Antipsychotics are dopamine antagonists, and work better against positive symptoms
2. Dopaminergic agents (amphetamine, cocaine, L-dopa) can induce psychosis
Psychological - subtle defects in thinking (e.g. jumping to conclusions) predisposes to delusions
79
What are the 3 clinical stages of schizophrenia? (No need for details)
Prodrome (At-Risk Mental State (ARM))
Acute phase
Chronic phase
80
Give details of the prodrome phase of schizophrenia.
Patients are usually late teens to early 20s
| Low-grade symptoms such as social withdrawal, loss of interest in work/relationships, but NO frank psychotic symptoms
81
Give symptoms of the acute phase of schizophrenia, giving details on the various types of each symptom. (3)
Delusions - Types are delusional perception (a real perception is interrupted in a delusional way) and passivity (belief that the movement, sensation, emotion or impulse is controlled by an outside form)
Hallucinations - Types of auditory hallucination include voices arguing about the patient, voices giving a commentary on the patient's actions and thought echo (voice says the patient's thought aloud)
Thought interference - Types are thought withdrawal (thoughts removed from patient's mind), insertion (placed into patient's mind) and broadcasting (being broadcast to others so everyone knows what they're thinking
Formal thought disorder - when thoughts are disconnected (loosening of associations) which produces disjointed speech (word salad is when words are so disconnected that sentences make no sense)
82
Give the symptoms of the chronic phase of schizophrenia. (5)
```
Apathy
Blunted affect
Anhedonia
Social withdrawal
Poverty of thought/speech
```
83
List the subtypes of schizophrenia. (5)
Paranoid (most common, mainly positive symptoms)
Catatonic (psychomotor disturbance)
Hebephrenic (15-25y/o, disorganised and chaotic mood/behaviour/speech, shallow affect, child-like behaviour)
Simple (negative features only)
Residual (prominent negative symptoms remain after positive symptoms subside)
84
What are the symptoms of catatonic schizophrenia (catatonia)? (7)
Stupor (immobile, mute and unresponsive (but appearing conscious))
Excitement - periods of extreme and apparently purposeless motor hyperactivity
Posturing - assuming and maintaining inappropriate and bizarre positions
Rigidity - holding a rigid posture against efforts to be moved
Waxy flexibility - patient's limbs offer minimal resistance to being placed in odd positions which are maintained for long periods (cataplexy)
Automatic obedience - to any instructions
Perseveration - inappropriate repetition of words or movements
85
What are Schneider's first-rank symptoms of schizophrenia? (4)
Delusional perception
Passivity
Delusions of thought interference
Auditory hallucinations
86
What is meant by mood disorder?
Severe depression or mania leading to psychotic symptoms.
87
What is meant by schizoaffective disorder?
Schizophrenic and affective symptoms develop together and are roughly evenly balanced.
88
What is meant by persistent delusional disorder?
Delusions with few or no hallucinations.
89
What is meant by schizotypal disorder?
Lifelong state of eccentricity with abnormal thoughts and affect which is regarded as a personality disorder - patients may be suspicious, cold or aloof with odd ideas without showing definite symptoms of schizophrenia.
90
What is the early intervention service (in the context of schizophrenia/psychosis)?
A service which aims to engage patients with very early symptoms - it offers antipsychotics and psychosocial interventions with the aim of keeping duration of untreated psychosis under 3 months.
91
Typical antipsychotics - examples (3), mechanism of action and side-effects.
Chlorpromazine
Haloperidol
Flupentixol decanoate
They are dopamine antagonists (mostly blocking the D2 receptor).
They can all cause extrapyramidal side-effects (dystonia, akathisia, Parkinsonism, tardive dyskinesia) at normal doses.
NOTE: See Laz's schizophrenia notes for more side-effects (there are loads).
92
Atypical antipsychotics - examples (6), mechanism of action and side-effects.
```
Olanzapine
Risperidone
Quetiapine
Aripiprazole
Clozapine
Amisulpride
```
They are dopamine antagonists and serotonin 5-HT2 receptor blockers.
Can cause extra-pyramidal side-effects (dystonia, akathisia, Parkinsonism, tardive dyskinesia) at high doses.
NOTE: See Laz's schizophrenia notes for more side-effects (there are loads).
93
What is neuroleptic malignant syndrome (NMS)? What are its symptoms/signs? How is it treated?
A rare but life-threatening side-effect of antipsychotics, usually triggered by a new treatment or increase of dose.
Muscle stiffness
Altered consciousness
Disturbance of autonomic function (fever, tachycardia and labile BP)
Raised CK and WCC
Stop antipsychotics immediately
Urgent medical treatment (ITU)
NOTE: Death may occur due to several causes e.g. rhabdomyolysis leading to renal failure.
94
What drug is first-line for treatment-resistant (refractory) schizophrenia?
NOTE: Treatment resistance = failure to respond to 2 or more antipsychotics, at least one of which is atypical, each given at a therapeutic dose for at least 6 weeks.
Clozapine
Warning - small risk of agranulocytosis (0.7%) - requires weekly blood tests to detect early signs of neutropenia.
95
Which psychological therapies should be considered in schizophrenics? (3)
CBT (all patients)
Family therapy
Concordance therapy (collaborative approach where patient is encouraged to consider pros and cons of the management)
96
The dopaminergic pathway of the brain starts in the ____ ____ area and projects to the ____ ____ (role in motivation/planning) and the ____ ____.
1. Ventral tegmental
2. Prefrontal cortex
3. Limbic system
97
What are the features of dependency (in the context of substance abuse)? (8)
```
Tolerance
Compulsion
Withdrawal
Problems controlling use
Continued use despite harm
Salience (primacy) - obtaining the substance becomes so important that other interests are neglected
Reinstatement after abstinence
Narrowing of the repertoire - loss of variation in the use of the substance
```
98
List some symptoms of alcohol withdrawal.
```
Headache
Nausea and vomiting
Tremor
Sweating
Insomnia
Anxiety/Agitation
Tachycardia
Delirium tremens
```
99
What is delirium tremens? What are its symptoms? How is it managed? What is the prognosis?
Severe alcohol withdrawal occurring around 48 hours into abstinence and usually lasting 3-4 days.
Symptoms:
Confusion
Hallucinations (especially visual e.g. formication)
Affective changes (fear or hilarity)
Gross motor symptoms (e.g. hand tremor)
Autonomic disturbance (sweating, tachycardia, hypertension, fever)
Delusions
Management:
Reducing benzodiazepine (chlordiazepoxide) regime and parenteral thiamine (pabrinex)
Manage potentially fatal dehydration and electrolyte abnormalities
Prognosis = 5% mortality.
100
What is Wernicke-Korsakoff Syndrome?
Combination of Wernicke's Encephalopathy and Korsakoff Psychosis seen in alcohol abuse.
Wernicke's:
Caused by acute thiamine deficiency
Triad of confusion, ataxia and ophthalmoplegia
Medical emergency
Korsakoff:
Irreversible anterograde amnesia
Patient can register new events but cannot recall them within a few minutes
Patients may confabulate to fill gaps in their memory
101
What investigations should you order in cases of alcohol misuse? (2) What might they show?
FBC - microcytic anaemia due to B12 deficiency
| LFTs - GGT rises with recent heavy alcohol use, transaminitis indicates hepatocellular damage
102
What are the stages of the Change Model for alcohol misuse? (6)
```
Pre-contemplation
Contemplation
Preparation
Action
Maintenance
Relapse
```
103
What is the purpose of giving benzodiazepines (e.g. chlordiazepoxide) in alcohol detox?
They replace alcohol and prevent any withdrawal symptoms, and can be gradually withdrawn and stopped.
104
What do we give as prophylaxis against Wernicke's Encephalopathy?
Thaimine (vitamin B1) IV or IM.
105
Acamprosate and disulfiram can be used to treat alcoholism - what do they do?
Acamprosate = anti-craving
| Disulfiram (antabuse) = mimics flush reaction to alcohol thereby making alcohol consumption unpleasant
106
Which drugs can be detected in a urine drug screen (UDS)? (5) For what duration of time after consumption is each of the drugs detectable in the urine?
```
Amphetamine - 2 days
Heroin - 2 days
Cocaine - 5-7 days
Methadone - 7 days
Cannabis - up to 1 month
```
107
What are the colloquial terms for smoking heroin (which people do before their tolerance has built-up) and for SC injections of heroin (which is often done once venous access becomes difficult)?
Smoking = Chasing
| SC injection = Skin popping
108
What are the local (4) and systemic (4) complications of IV drug use?
Local: Abscess, cellulitis, DVT, emboli
Systemic: Septicaemia, infective endocarditis, blood-borne infections, increased risk of overdose
109
What is the antidote for heroin?
Naloxone
NOTE: After giving naloxone, patients may enter withdrawal.
110
How long after injection does heroin withdrawal typically start?
Starts 6 hours after injection and peaks at 36-48 hours.
111
What are 'the runs'? They are associated with overdose of which drug?
Diarrhoea, vomiting, lacrimation and rhinorrhoea
Heroin
112
Substitute prescribing of which drugs can be used to help patients with heroin addiction?
Methadone (liquid) - this is a full agonist of opiate receptors.
Buprenorphine (sublingual tablet) - this is a partial agonist of opiate receptors.
113
Which drug can be used to prevent relapse of heroin use after detox? How does it work?
Naltrexone - it's an opiate antagonist which blocks the euphoric effects of opiates.
114
What is the psychoactive compound in cannabis?
delta-9-tetrahydrocannabinol (THC) - acts on cannabinoid receptors in the brain.
115
Stimulants potentiate the effects of neurotransmitters, increasing energy, alertness and euphoria, and decreases need for sleep. They increase confidence and impulsivity.
What are their side-effects? (6)
Which drugs can be used in the short-term to help with withdrawal anxiety?
Arrhythmias, hypertension, stroke, anxiety, panic and drug-induced psychosis.
Benzodiazepines.
116
What is the colloquial term for the use of crack cocaine and heroin together?
Speedballing.
117
What is Khat?
A mild stimulate that comes in chewable leaves that can cause florid psychosis.
118
What is the mechanism of action of ecstasy?
Causes serotonin re-uptake inhibition and release.
119
What is synaesthesia?
Experience of a sensation in another modality (e.g. hearing a smell) - it can occur with hallucinogen use.
120
What is behavioural toxicity?
The accidental harm that occurs when people act on drug-induced beliefs e.g. being able to fly (most common with hallucinogens).
121
What is used to treat benzodiazepine overdose?
Flumazenil.
122
How do sedatives e.g. benzos work?
Enhance GABA transmission.
123
List 4 hallucinogens.
LSD
Phenylcyclidine
Ketamine
Magic mushrooms
124
Define learning disability.
A developmental condition characterised by global impairment of intelligence and significant difficulties in socially adaptive functioning.
125
Why is the prevalence of learning disability rising?
Partly due to the increased survival of very premature babies.
126
List the antenatal causes of learning disability. (6)
```
Genetic (e.g. PKU)
Foetal alcohol syndrome
Drugs
Medications
Smoking
Infection (e.g. rubella)
```
127
List the perinatal causes of learning disability. (4)
Neonatal hypoxia
Birth trauma
Hypoglycaemia
Prematurity
128
List the postnatal causes of learning disability. (5)
```
Social deprivation
Malnutrition
Lead
Infections (e.g. meningitis)
Head injury
```
129
What are behavioural phenotypes?
Commonly recognised behaviours in particular syndromes e.g. self-harm in Lesch-Nyhan syndrome.
130
How is learning disability categorized?
Mild
Moderate
Severe
Profound
131
What is the leading cause of death in patients with learning disabilities?
Respiratory infections.
132
What is diagnostic overshadowing in the context of learning disability?
Attributing all abnormal characteristics to the learning disability - in reality patients with learning disabilities are likely to have comorbid mental health problems and autism-spectrum disorders.
133
What is Asperger's syndrome?
Autism with normal intelligence.
134
List 4 prevention strategies for the development of learning disabilities.
Education (e.g. risks of alcohol during pregnancy)
Improved antenatal/perinatal care
Genetic counselling
Early detection and treatment of reversible causes (e.g. excluding phenylalanine in babies with PKU)
135
How is sexual dysfunction categorized?
Primary - normal function was never obtained
| Secondary - loss of function
136
Give 2 treatments for low libido.
Sensate focus therapy:
1. Intercourse is banned
2. Non-genital caressing (focus on pleasure and relaxation)
3. Genital touching to achieve arousal and subsequent orgasm
4. In time, intercourse occurs naturally
Timetabling sex - helps partners with different libidos compromise.
137
How is hyper sexuality treated?
CBT-based treatments.
138
List the organic causes of erectile dysfunction. (6)
```
Diabetes
Arteriosclerosis
Neurological (e.g. autonomic neuropathy)
Pituitary failure
Medication (antidepressants, antipsychotics, antihypertensives, beta-blockers and diuretics)
Substance misuse
```
139
What blood tests should be ordered in patients with erectile dysfunction? (3)
Testosterone and sex hormone (may see low testosterone/hyperprolactinaemia)
Glucose (diabetes)
LFTs/GGT (alcohol misuse)
140
How can we treat erectile dysfunction?
Change modifiable risk factors (stop smoking, treat diabetes etc.)
Psychological approaches
Physical treatments:
1. Phosphodiesterase-5 inhibitors (e.g. sildenafil)
2. Intracavernosal prostaglandin self-injections before intercourse
3. Vacuum pumps
141
Which drugs may help with premature ejaculation?
SSRIs
142
How can delayed ejaculation be treated?
```
Psychotherapy
Advice on varying sexual techniques
Medication review (SSRIs could cause delayed ejaculation)
```
143
Give 6 female, and 4 male causes of dyspareunia.
Female - infection, episiotomy, endometriosis, tumours, vaginal dryness, vaginismus
Male - urethritis, prostatitis
(Both - psychological)
144
What is vaginismus and how is it treated?
Painful, involuntary spasm of the vaginal muscles when penetration is attempted.
Education, relaxation, self-exploration, insertion of 'trainers' of increasing sizes to become accustomed to penetration.
145
What are paraphilias? List 4 of them.
Disorders of sexual preference - they occur almost exclusively in men and only require treatment if they cause harm/distress.
Fetishism - sexual arousal and gratification relies on an object rather than a person
Paedophilia
Sadism - inflicting pain causes arousal
Masochism - humiliation or suffering causes arousal
NOTE: Anti-androgens may be useful in dangerous situations e.g. paedophiles who feel that they may be overwhelmed by sexual urges.
146
What are the treatment options for disorders of gender identity (transsexual patients)? (2)
Hormone therapy
| Gender reassignment surgery
147
Define dementia.
Acquired, chronic and progressive cognitive impairment sufficient to impair activities of daily living. Problems should have been present in clear consciousness for at least 6 months.
148
List the causes of low MMSE in the elderly. (7)
```
Dementia
Delirium
Psychiatric illness (depression, anxiety, psychosis)
Learning disability
Sensory impairment
Language barrier
Feeling unwell, tired or irritable
```
149
What percentage of people over 80 years of age have dementia?
20%
150
What is the most common form of dementia? What proportion of cases does it make up?
Alzheimer's
2/3 of all dementia
NOTE: The 2nd most common form is vascular dementia and the 3rd is dementia with Lewy bodies.
151
Give 4 genetic risk factors for Alzheimer's disease.
Presenilin 1
Presenilin 2
Beta-amyloid precursor protein
Apolipoprotein 4
152
Give 4 pathology findings in Alzheimer's disease.
Atrophy due to neuronal loss (hippocampus is affected early)
Plaque formation - due to abnormal cleavage of amyloid precursor protein into beta-amyloid (insoluble)
Intracellular neurofibrillary tangles may up of hyperphosphorylated Tau proteins kill neurones
Cholinergic loss
153
What is the classical clinical presentation of Alzheimer's disease?
The four As:
Amnesia - recent memories lost first, disorientation occurs early
Aphasia - muddled speech and word-finding problems
Agnosia - problems recognising things/people
Apraxia - inability to carry out skilled tasks despite normal motor function
154
Vascular dementia is caused by...
...infarcts due to thromboemboli or atherosclerosis.
NOTE: There is a stepwise progression, and symptoms are dependent on the site of the infarct.
155
CT of a patient with vascular dementia will show what?
Multiple lucencies.
156
What are Lewy bodies?
Eosinophilic intracytoplasmic neuronal structures consisting of alpha-synuclein and ubiquitin. In dementia with Lewy bodies, they are generally seen in the cingulate gyrus and neocortex, but in Parkinson's they are found in the brainstem.
157
How does dementia with Lewy bodies generally present?
Fluctuating confusion with marked variation in levels of alertness
Vivid visual hallucinations
Spontaneous Parkinsonian sings (may present late)
158
Why does dementia with Lewy bodies often get mistaken for delirium?
Fluctuating cognition and hallucinations.
159
What should you not prescribe for someone with Lewy body dementia?
Antipsychotics - extreme sensitivity can result in death.
160
List the causes of reversible dementia affecting the brain (3), endocrine system (4) and vitamin deficiencies (4).
Brain: Subdural haematoma, space occupying lesion, normal pressure hydrocephalus
Endocrine: Hypothyroidism, hyperparathyroidism, Addison's disease, Cushing's syndrome
Vitamin deficiencies: B12, folate, thiamine, niacin
161
What is pseudodementia?
The presence of memory problems in severe depression.
162
What psychological therapies can be used to treat dementia? (5)
Behavioural - identify underlying triggers for difficult/risky behaviours (e.g. wandering may be due to disorientation, boredom or anxiety).
Reminiscence therapy - talking about the old days enhances a sense of belonging.
Validation therapy - reassure and validate the emotion behind what is said.
Multisensory therapy - as dementia advances and speech is lost, it may be easier to respond to touch, music etc.
Cognitive stimulation therapy - memory training and re-learning.
163
What psychotropic medication can be used to treat dementia?
Acetylcholinesterase inhibitors (donepezil, rivastigmine) - give symptomatic relief but have no effect on progression of dementia.
NOTE: Behavioural disturbance may require sedatives as a last resort (e.g. trazodone, sodium valproate, haloperidol).
164
Define delirium.
Acute and transient global brain dysfunction with clouding of consciousness.
165
What are the 2 types of behavioural change seen in delirium?
Hyperactivity - agitation and aggression
| Hypoactivity - lethargy, stupor, drowsiness and withdrawal
166
Semantic dementia is characterised by...
...progressive loss of understanding of verbal and visual meaning.
167
What is progressive non-fluent aphasia?
A type of frontotemporal lobar degeneration which begins with naming difficulties and progresses to mutism.
NOTE: Other FLDs are semantic dementia and frontotemporal dementia (Pick's disease).
168
What is the pattern of inheritance of Huntington's disease? What mutation is it caused by?
Autosomal dominant - caused by CAG trinucleotide repeat in the Huntingtin gene on chromosome 4.
169
What is anticipation in the context of Huntington's disease?
Lengthening CAG repeats occur with each inheritance so onset is younger in subsequent generations.
170
What is the pathophysiology of Huntington's disease?
Deposits of abnormal Huntingtin protein cause atrophy of the basal ganglia and thalamus as well as some cortical lobe loss (particularly frontal lobe).
171
What would you be likely to see in a CT/MRI head of a patient with Huntington's?
Caudate nucleus atrophy.
172
What are the clinical features of Huntington's?
Personality/behavioural changes
Depression/irritability/euphoria
Chorea of the limbs, trunk, face and speech muscles
Wide-based lurching gait
173
Give 3 causes of normal pressure hydrocephalus. What is NPH?
Meningitis
Head injury
Idiopathic
CSF absorption is impaired with normal communication between ventricles - CSF accumulates in the ventricles but the pressure remains normal as CSF production adjusts to compensate.
174
In normal pressure hydrocephalus, distortion of periventricular white matter tracts leads a triad of...
Dementia (subcortical)
Unsteady gait
Urinary incontinence
175
What is the most common prion disease (transmissible spongiform encephalopathy)? What is the pathophysiology of prion diseases?
Sporadic CJD
Normal prion protein changes to an insoluble form which appears to act as a template for further transformation of normal to abnormal prion protein. Accumulation of abnormal proteins leads to spongiform and amyloid changes.
176
What is an amnesic syndrome? Give 3 causes.
A syndrome characterised by profound anterograde memory loss.
Hypoxia
Encephalitis
Carbon monoxide poisoning
NOTE: Korsakoff syndrome is the most common type of amnesic syndrome.
177
Define transient global amnesia. What do we think may cause it? What can precipitate it?
Acute global memory loss, lasting 1-24 hours.
May be due to transient ischaemia of memory structures.
Sometimes precipitated by physical or emotional stress.
178
On what 3 factors do we base the severity of head injury?
GCS
Duration of coma
Duration of post-traumatic amnesia
179
What is Parkinson's disease? What is the triad of extrapyramidal symptoms?
An idiopathic movement disorder caused by degeneration of the dopaminergic neurones in the substantia nigra.
Tremor (pill-rolling)
Rigidity
Bradykinesia
180
How common is depression in Parkinson's patients?
40% of Parkinson's patients have depression.
181
How common is dementia in Parkinson's patients? What drugs can we used to treat it?
80% of Parkinson's patients get dementia - bradyphrenia is a common early symptom.
We can treat with acetylcholinesterase inhibitors.
182
How can we distinguish between Parkinson's disease and Lewy body dementia?
PD - Parkinson's comes first, then dementia.
| LBD - Dementia comes first, then Parkinson's.
183
What proportion of Parkinson's patients get psychotic symptoms? What do we think may cause this?
40%.
We think it may be caused by use of dopaminergic anti-Parkinson's drugs, so we try to find a balance between too little and too much dopamine.
184
How common is depression in multiple sclerosis patients?
up to 50% of MS patients get depression.
185
How common is depression in stroke patients?
1/3 stroke patients get depression.
186
How common is depression in epileptics?
50% of epileptics get depression.
187
List and explain the behavioural and cognitive theories of anxiety.
Classical conditioning - repeating pairing of a neutral stimulus with a frightening one results in a fear reaction to a neutral stimulus.
Negative reinforcement - behaviours that relieve anxiety are repeated (e.g. running away), which prevents habituation.
Cognitive theories - worrying thoughts are repeated in an automatic way which induces and maintains the anxiety response.
Attachment theory - quality of attachment between children and their parents affects their confidence as adults.
188
Define general anxiety disorder.
Anxiety that is not triggered by a specific stimulus, but instead is continuous and generalised. Diagnosis requires symptoms to be present for at least 6 months.
189
What is a phobic anxiety disorder? Give 3 examples.
A disorder where intermittent anxiety occurs in specific but quite ordinary circumstances.
Agoraphobia
Social phobia
Panic disorder (aka episodic paroxysmal anxiety)
190
What is agoraphobia?
Fear of being unable to easily escape to a safe place (usually home) - this includes fear of open places and fear of situations that are confined and difficult to leave without attracting attention.
NOTE: Onset tends to be during patient's 20s-30s.
191
What is social phobia?
Fear of being scrutinised or criticised by other people - people can tolerate anonymous crowds but small groups are intimidating.
NOTE: Patients often self-medicate with alcohol/drugs.
192
What is panic disorder (aka episodic paroxysmal anxiety)?
A condition of intermittent anxiety without an obvious trigger - patients have panic attacks which may present with chest tightness, breathing difficulty, palpitations, sweating etc., and they experience alarming thoughts which cause further panic until they gain reassurance/are engaged in safety behaviours.
193
Panic attacks are self-limiting - how long do they usually last?
<30 mins
194
List 3 rating scales for anxiety.
GAD7 questionnaire
Beck anxiety inventory
Hospital anxiety and depression scale
195
Which 2 forms of therapy can be used to treat anxiety disorders?
CBT
| Exposure therapy
196
What are the pharmacological options for the management of anxiety disorders? (5)
SSRIs
TCAs e.g. clomipramine, imipramine
Buspirone (a partial serotonin agonist)
Benzodiazepines (useful for short-term treatment e.g. whilst waiting for SSRIs to work)
Beta-blockers - used to treat adrenergic symptoms e.g. tremor/palpitations
197
How common is OCD?
Affects 1% of the population.
198
What proportion of OCD patients have anankastic personality traits (rigidity, orderliness)?
1/4 of patients with OCD have anankastic personality traits.
199
Give 3 diseases associated with OCD.
Sydenham's chorea
Encephalitis lethargica
Tourette's syndrome
200
# Define 'obsessions' and 'compulsions'.
Common themes of obsession in OCD include contamination, aggression (thoughts of harming self or others), infection and morality (sex and religion).
Obsessions - recurrent unwanted intrusive thoughts, images or impulses that enter the patient's mind despite attempts to resist them.
Compulsions - repeated, stereotyped and seemingly purposeful rituals that the patient feels compelled to carry out, even if they are irrational and may lack any obvious link to the obsession.
NOTE: In OCD, the patient recognises the thoughts as irrational and their own (unlike delusions and thought insertion).
201
What is anankastic personality disorder?
Lifelong personality of rigidity with high standards of orderliness and hygiene.
202
Which class of drugs is used to treat OCD?
SSRIs
NOTE: Clomipramine (TCA) is also effective.
203
Define acute stress reaction. Which class of drugs can be used to treat this?
A transient state starting within minutes of trauma and resolving spontaneously within hours (1-3 days maximum). The patient may be anxious, dazed, disorientated and agitated, and may experience amnesia/derealisation.
Benzodiazepines can be used to treat it but do not prevent later PTSD.
204
What is the lifetime prevalence of PTSD?
6.8%
205
There is often a latency period between the triggering event and the onset of PTSD - how long is this period usually?
PTSD usually begins within 6 months of trauma.
206
What are re-experiencing, avoidance and hyperarousal in the context of PTSD?
Re-experiencing - flashbacks, nightmares and intrusive memories of the trauma.
Avoidance - avoiding reminders of the event.
Hyperarousal - persistent inability to relax, hyper-vigilance, enhanced startle reflex, insomnia, poor concentration and irritability.
207
How can we manage PTSD? (3)
CBT
Eye movement desensitisation and reprocessing (EMDR)
Pharmacological treatment - SSRIs are first line
208
What is an adjustment disorder?
Where a person's reaction to life changes that require adaptation to cope (e.g. moving to university) is greater than expected - it is not severe enough to diagnose anxiety or depressive disorder.
NOTE: Symptoms usually start within 1 month of the stressor and resolve within 6 months.
209
Give and explain the 3 theories of medically unexplained symptoms (functional/psychosomatic disease).
Somatisation - unconscious expression of psychological distress through physical symptoms.
Psychiatric illness - depression and anxiety symptoms can be psychological and physical (e.g. muscle aches, constipation, palpitations).
Cognitive models - an individuals interpretation of normal physiology can create anxiety and perpetuate MUS e.g. someone concerned about palpitations may misinterpret rapid HR whilst anxious as a feature of heart attack.
210
What is hypochondriasis?
An extreme form of health anxiety where patients believe they have a specific illness rather than presenting with inexplicable symptoms.
211
What is factitious disorder?
Deliberate production of symptoms to receive medical treatment - extreme cases = Munchausen's syndrome.
212
What is malingering?
Feigning symptoms to obtain external reward e.g. escape military service.
213
What is chronic fatigue syndrome (aka myalgic encephalomyelitis)? How can we treat it?
Extreme fatigue which may follow viral infection or arise spontaneously.
There is strong evidence for graded exercise (scheduled and gradually increasing activity).
214
What is somatisation disorder? How much more common is it in women?
Multiple medically unexplained symptoms affecting any system in the body.
10x more common in women.
215
What are conversion disorders? Give some examples of how they may present.
Where an internal conflict is unconsciously converted into neurological symptoms.
```
Presentations are acute, specific and often dramatic:
Paralysis
Blindness
Aphonia
Seizures
Psychogenic amnesia
Multiple personality disorder
Fugue
Stupor
```
216
What is la belle indifference? It may be seen in conversion disorders.
A relative lack of concern despite obviously worrying symptoms.
217
What are the 4 main diagnostic points for anorexia nervosa?
BMI < 17.5 (or weight 15% less than expected)
Deliberate weight loss
Distorted body image
Endocrine dysfunction - hypothalamo-pituitary-gonadal axis affected, causing amennorhoea (women), impotence (men) and loss of libido
218
When attempting nutritional management and weight restoration in patients with anorexia nervosa, what is usually seen as a realistic weekly weight gain target?
0.5-1kg/week
219
List 4 psychotherapies that can be used to treat anorexia nervosa.
Motivational interviewing
Family therapy
Interpersonal therapy
CBT
220
Give 3 indications for inpatient treatment of anorexia nervosa.
BMI < 13
Serious physical complications
High suicide risk
221
How does bulimia nervosa present clinically? (4)
Binge eating
Purging
Body image distortion
BMI > 17.5 - patients usually have a normal or slightly increased weight
222
What class of drugs can be used to manage bulimia nervosa?
SSRIs (Fluoxetine) - reduce binging and purging by enhancing impulse control
223
What is refeeding syndrome? What causes it?
In patients with eating disorders, it is a complication of establishing adequate food intake, characterised by electrolyte imbalance.
Low phosphate, potassium and magnesium - caused by sudden intracellular movement of electrolytes due to switch from fat to carbohydrate metabolism and associated increased secretion of insulin.
224
What are the baby blues? How common is it?
A distressing but normal period of a few days after giving birth, where mothers feel weepy, irritable and muddled, and may experience trouble sleeping.
It occurs in 50-75% of mothers.
225
How common is postnatal depression?
1 in 10 mothers will suffer from PND in the year after giving birth.
226
How can postnatal depression differ from normal depression in the symptoms experienced?
Depressive cognitions tend to relate to the baby e.g. feeling like a failure as a mother.
Recurrent intrusive thoughts about harming the baby can occur, as well as distressing obsessions.
227
Which unit is best for a mother with postnatal depression who is experiencing severe suicidal or infanticidal ideation?
The mother and baby unit (MBU).
228
Pharmacological management of postnatal depression is largely similar to normal depression, but care must be taken when using drugs in breastfeeding mothers (antidepressants can be secreted in breast milk) - what drug should be avoided?
Lithium should be avoided.
NOTE: Low-dose amitriptyline is generally safe.
229
How common is puerperal psychosis?
Occurs once in every 500/1000 births.
230
When does puerperal psychosis usually occur?
2 weeks after giving birth.
231
How does puerperal psychosis present?
Rapid onset often starting with insomnia, restlessness and perplexity.
This is followed by psychotic symptoms in one of 3 patterns:
Delirium
Affective (depression/mania)
Schizophreniform (like schizophrenia)
232
ECT may be required to treat severe cases of puerperal psychosis - what is the prognosis of puerperal psychosis?
Most patients recover within 6-12 weeks.
233
What is the most common cause of maternal death in the UK?
Suicide.
234
How common is autism?
1 in 1000 children.
235
What is autism spectrum disorder?
When the patient does not fit the full criteria for diagnosing autism but is similar.
236
Give 3 risk factors for autism.
Obstetric complications, perinatal infection, genetic disorders.
237
How does autism present clinically? (3)
Reciprocal social interaction
Communication abnormalities
Restricted behaviours and routine
238
What is concrete thinking?
Where ideas are taken literally.
239
What proportion of autistic patients have significant learning disabilities?
75%
240
What proportion of autistic patients suffer from seizures?
25%
241
What is specific language disorder?
Delayed speech with normal IQ and social ability.
242
What is Asperger's syndrome?
An autism spectrum disorder where patients have poor social skills and restricted interest, but normal language and IQ.
243
What is the gender distribution of depression before and after puberty?
Before - boys = girls
| After - girls > boys
244
What is separation anxiety disorder?
Children are clingy and become distressed on separation from their parents - exploration of the family history may reveal threatened or unmourned loss.
245
Define primary and secondary enuresis.
```
Primary = toilet training was never mastered.
Secondary = dryness was achieved for at least 1 year but has been lost.
```
246
What are the most common causes of primary and secondary enuresis respectively?
```
Primary = delayed maturation of the bladder's innervation.
Secondary = stress-related.
```
247
Define encopresis.
Inappropriate defection after age 4 when bowel control is expected.
248
What is the most common cause of encopresis?
Overflow incontinence due to constipation.
249
What is elective mutism?
Where a child can speak but chooses not to in certain situations.
250
How common is ADHD? What is the gender distribution?
ADHD affects 2% of children.
It is 3x more common in boys.
251
How does ADHD present clinically?
Present by the age of 6 years
Must be persistent and pervasive across different situations
Hyperactivity
Inattention
Associated features such as recklessness/impulsivity, clumsiness, disobedience and social disinhibition
252
What is Conner's rating scale?
A questionnaire that can be used to help diagnose patients with ADHD.
253
Which stimulant drugs can be used to treat ADHD? What are their side-effects? (2)
Methylphenidate (Ritalin) and dexamphetamine.
Side-effects:
Appetite suppression
Insomnia
NOTE: Drug holidays may be needed to limit growth retardation.
254
What are the risk factors for conduct disorder? (6)
```
Urban upbringing
Deprivation
Parental criminality
Harsh and inconsistent parenting
Maternal depression
Family history of substance misuse
```
255
What are the 2 types of conduct disorder?
Socialised CD - child has peer group (often sharing in antisocial behaviour)
Unsocialised CD - rejected by other children making them more isolated and hostile
256
What is oppositional defiant disorder?
A milder form of conduct disorder which tends to occur in children < 10 years old.
257
How can tic disorders be managed pharmacologically?
Clonidine (alpha-2 agonist)
| Haloperidol (antipsychotic)
258
Define personality.
A set of consistent thoughts, feelings and behaviours shown across time in a variety of settings.
259
What are 'The Big 5' personality traits?
```
Openness ti experience
Conscientiousness
Extraversion
Agreeableness
Neuroticism
```
(OCEAN)
260
The 3 Ps can help to differentiate a personality disorder from a personality trait. What are the 3 Ps?
Pervasive - occurs in all/most areas of life
Persistent - evident in adolescence and continues through childhood
Pathological - causes distress to self or others, impairs function
261
What are the ICD-10 criteria for diagnosis of a personality disorder?
```
Relationships affected
Enduring
Pervasive
Onset in childhood/adolescence
Result in distress
Trouble in occupational/social performance
```
(REPORT)
262
What are the 3 clusters in which personalities tend to occur?
Cluster A - odd or eccentric:
- Paranoid
- Schizoid
Cluster B - dramatic, erratic or emotional:
- Histrionic
- Emotionally unstable
- Dissocial
Cluster C - anxious or fearful:
- Anankastic
- Anxious (avoidant)
- Dependent
263
How common are personality disorders?
Around 10% of the population have a personality disorder.
264
What theories exist as to the aetiology of personality disorders?
1. Quality of early relationships and environment affects how people see themselves/the world.
2. Disorders occur as a form of psychological defence:
- Acting out - impulses are expressed through actions without conscious awareness of the underlying emotion (e.g. self-harm)
- Splitting - other people are thought of in polarised terms (idealised or denigrated)
- Projection - uncomfortable feelings are put onto someone else and experienced as belonging to them
3. Neurotransmitter theories - low serotonin levels in dissociate personality disorder have been demonstrated.
265
What are the features of paranoid personality disorder?
```
Sensitive
Unforgiving
Suspicious
Possessive and jealous of partners
Excessive self-importance
Conspiracy theories
Tenacious sense of rights
```
(SUSPECT)
266
What are the features of schizoid personality disorder?
```
Anhedonic
Limited emotional range
Little sexual interest
Apparent indifference to praise/criticism
Lacks close relationships
One-player activities
Normal social conventions are ignored
Excessive fantasy world
```
(ALL ALONE)
267
What are the features of histrionic personality disorder?
```
Attention seeking
Concerned with own appearance
Theatrical
Open to suggestion
Racy and seductive
Shallow affect
```
(ACTORS)
268
What are the 2 types of emotionally unstable personality disorder? What are the features that belong to BOTH subtypes?
Borderline personality disorder and impulsive type personality disorder.
```
Features belonging to both:
Affective instability
Explosive behaviour
Impulsive
Outbursts of anger
Unable to plan or consider consequences
```
(AEIOU)
269
What are the features of borderline personality disorder?
```
Self-image unclear
Chronic empty feelings
Abandonment fears
Relationships are intense and unstable
Suicide attempts and self-harm
```
(SCARS)
270
What are the features of impulsive type personality disorder?
```
Lacks impulse control
Outbursts of threats or violence
Sensitivity to being thwarted or criticised
Emotional instability
Inability to plan ahead
Thoughtless of consequences
```
(LOSE IT)
271
What are the features of dissocial personality disorder?
```
Forms but cannot maintain relationships
Irresponsible
Guiltless
Heartless
Temper easily lost
Someone else's fault
```
(FIGHTS)
272
What are the features of anankastic personality disorder?
```
Doubtful
Excessive detail
Tasks not completed
Adheres to the rules
Inflexible
Likes own way
Excludes please and relationships
Dominated by intrusive thoughts
```
(DETAILED)
273
What are the features of anxious (avoidant) personality disorder?
```
Avoids social contact
Fears rejection/criticism
Restricted lifestyle
Apprehensive
Inferiority
Doesn't get involved unless sure of acceptance
```
(AFRAID)
274
What are the features of dependent personality disorder?
```
Subordinate
Undemanding
Feels helpless when alone
Fears abandonment
Encourages others to make decisions
Reassurance needed
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(SUFFER)
275
What forms of therapy are available for patients with personality disorders? (6)
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CBT
Dialectical behaviour therapy (DBT)
Cognitive analytical therapy (CAT)
Mentalisation
Therapeutic communities
Psychodynamic and psychoanalytical psychotherapy
```
276
What drug classes can be used to treat personality disorders? (3)
Antipsychotics - may reduce impulsivity and aggression
Antidepressants - may reduce impulsivity and anxiety
Mood stabilisers - may be used for labile effect
277
Selective memory for negative events and pathological guilt are 2 forms of depressive cognition. What makes guilt 'pathological'?
If it is disproportionate to the degree and timescale for which one should expect to experience guilt.
278
How can we categorise depressive cognitions?
Past - selective memory and pathological guilt
Present - Useless, worthless, burden on others
Future - Hopelessness and pessimism
279
What are the risks of treating BPAD as depression?
Giving antidepressants could trigger mania
- could lead to impulsive behaviours
- could worsen mood swings (rapid cycling)
280
How can you tell if someone has true loss of touch with reality in cases of psychotic depression?
If they acted on or reacted to their delusions and hallucinations.
281
What are the 4 main types of depression?
Unipolar depression
Bipolar depression
Psychosocial depression
Psychotic depression
282
What is the 'catch-up phenomenon' in the context of depression?
If you take antidepressants and then stop, it can leave your mood at a lower level than before starting the antidepressants.
283
What drug can be given alongside antidepressants to augment the treatment?
Quetiapine
| alternative = lithium
284
What are the 4 aspects of capacity?
Understanding (5%)
Retention (5%)
Weighing up options (90%)
Communicating (not often an issue that affects capacity)
285
What are the 2 types of evidence? Which type of evidence applies to the mental capacity act?
Criminal (beyond reasonable doubt)
| Civil (balance of probability) - this applies to the MCA
286
What is proportionality in the context of mental capacity?
The more severe the clinical scenario, the less evidence you need to determine a lack of capacity.
287
What class of drug is mirtazapine? What 2 conditions is it used for?
Mirtazapine is a noradrenergic and selective serotoninergic antidepressant (NaSSA).
It is used for anxiety and depression.
288
What is the best SSRI for avoiding weight gain? What is the best SNRI?
SSRI - fluoxetine
| SNRI - venlafaxine
289
SSRIs have a 60% risk of causing sexual dysfunction - which drug can be used if this becomes a problem in depression?
Mirtazapine - it causes placebo-level sexual dysfunction.
290
Give 3 low cardiac risk and 2 high cardiac risk antidepressant drugs.
Low risk:
Olanzapine
Aripiprazole
Mirtazapine
High risk:
Clozapine
Venlafaxine
291
What are the side-effects of aripiprazole (1), quetiapine (2), olanzapine (2) and risperidone (3)?
Aripiprazole - Initial akathisia
Quetiapine - Sedation and weight gain
Olanzapine - Weight gain and metabolic syndrome
Risperidone - Hyperprolactinaemia, extrapyramidal symptoms and sedation
292
Which drugs are used for rapid tranquillisation?
Haloperidol (5mg) + lorazepam (1mg)
293
Acetylcholinesterase inhibitors can be used to manage mild-to-moderate dementia. Give 3 examples of acetylcholinesterase inhibitors.
Donepezil
Rivastigmine
Galantamine
294
Which drug can be used to treat moderate-to-severe dementia?
Memantine
295
Give an example of a non-stimulant drug that can be used to treat ADHD.
Atomoxetine
