Psychiatry SAQs and SBAs Flashcards
A 27 year old woman presents to the Emergency Department following an overdose. The patient describes deeply engrained and enduring behaviour patterns, manifesting as inflexible responses to a broad range of personal and social situations.
What time frame might suggest that this patient has a PD?
problems started in adolescence and continued throughout adulthood
A 19 year old woman is admitted to a psychiatric ward. She has been hearing voices inside her head. There are 2 voices and they talk directly to her, telling her to kill herself. She has been self-harming on a regular basis for the last 5 years.
How would you best describe the voice hearing experience of this patient?
pseudohallucinations - they are in her head and are therefore not true hallucinations
A 55 year old man is taken to see his GP by his family. They report that he has had a marked change in personality. He is now extremely antisocial. He swears constantly, and does not seem to care about upsetting people. He has been in several fights both with strangers and members of his own family. He has recently taken to gambling heavily and got into significant debt. He seems to completely lack in empathy.
What is the most likely diagnosis?
Fronto-temporal dementia- often presents as change in personality
A 21 year old woman with an emotionally unstable personality disorder is advised to start psychotherapy.
The therapy includes weekly individual sessions and weekly life-skills group sessions that teach skills in 4 domains: mindfulness, distress tolerance, regulation of emotions and interpersonal effectiveness. The therapy is designed to last at least 1 year.
What therapy is being described here?
Dialectical Behaviour therapy
A 29 year old woman is in weekly therapy for an emotionally unstable personality disorder.
The patient begins to describe feelings that the therapist is too controlling. When this is explored in therapy the patient realises that this feeling is a repetition of reactions and feelings that she has towards her mother, which she has had since childhood. The patient was not consciously aware that she was doing this until it was explored in therapy.
What psychodynamic process is being described?
transference
Define counter-transference
the therapist’s unconscious (and often conscious) reactions to the patient and to the patient’s transference
Define transference
unconscious transfer of feelings and attitudes from the past onto the therapist
Define therapeutic alliance
a measure of the therapist’s and client’s mutual engagement in the work of therapy
A woman with nausea, abdominal pain, dysmenorrhoea, had several investigations.The woman does not identify a specific illness from which she fears she may be suffering. No specific cause is identified.
What is the most likely diagnosis?
Somatization disorder (also called Briquet’s syndrome)
a mental disorder characterised by multiple
recurring, frequently changing complaints about somatic symptoms, of at least 2 years duration
Define hypochondriasis
persistent belief, of at least six months’ duration, of the presence of a minimum of two serious physical
diseases (of which at least one must be specifically named by the patient)
Which is the most common compulsion in OCD?
Checking
A 17 year old was sent home from his sixth form as he smelt of alcohol. The GP refers the family to CAMHS where his dad his dad reports that his son is less interested in exploring new things. He never joins in on conversation when there are visitors at home; he gets distressed and sweats profusely when attending parties and other occasions.
What is the most likely diagnosis?
social phobia - use of alcohol is a dyfunctional coping strategy (essentially “self-medication” with an easily available anxiolytic)
Cognitive theory suggests that what is the most significant underlying factor in anxiety disorders?
Catastrophisation - higher perception of threat and of an adverse outcome
A 35 year old soldier is diagnosed with PTSD as a result of trauma he experienced in the battlefield when posted in Iraq. He has only just disclosed symptoms that have enabled a PTSD diagnosis to be confidently made. He has been suicidal and a month ago took an overdose.
What is the most appropriate treatment?
trauma focused CBT
EMDR is used more for non-combat related trauma
A 21 year old woman has a fear of injections and has presented as she wishes to become pregnant and knows she will probably then need to have some blood taken.
You think that she has a phobic disorder and try to explain principles of exposure therapy. She says exposure won’t work for her, because if she sees a needle coming towards her she faints.
What is the explanation for the alleged fainting
episodes?
This is vasovagal syncope due to a diphasic response in blood-injury phobia
Practically this means that if exposure is to be attempted then something is necessary to prevent syncope - this is done by teaching the patient a technique called “applied tension”
(which prevents venous pooling, etc.):
Spot diagnosis: 35-year old man who is concerned that his chronic worrying will make him ill
Generalised anxiety disorder (GAD)
Spot diagnosis : 75-year old woman with low mood and beliefs that her bowels have stopped working and her heart is no longer beating
Depressive episode with psychotic features
What class of medication is clomipramine?
A tricyclic antidepressant (TCA) – (but one that has a significant effect on serotonin: most tricyclics have a significant effect on norepinephrine/noradrenaline)
What are the likely side effects of clomipramine?
Similar to SSRIs but can cause some sedation – caution regarding driving and machinery use!
Would it be wise to offer clomipramine to a patient at risk of suicide?
No. TCAs are potentially much more toxic than SSRIs in overdose (marked cardiotoxicity). If the indication for use is very strong, consider offering very short repeat prescriptions and ensure safety plans are robust.
What is the Three-Component Model of Emotions used in CBT?
thoughts, feelings and behaviours
Describe the classic generic model of panic (sometimes called the Clark model)
trigger stimulus
perceived threat
apprehension
body sensations
interpretations of sensations as catastrophic
Interpersonal therapy (IPT) is a NICE recommended treatment for which condition?
depression
Family therapy is used for:
most commonly an intervention for children
used in eating disorders (particularly with younger anorexic patients)
used as an adjunctive treatment in schizophrenia e.g. prevention of relapse of schizophrenia in patients whose families show high expressed emotion (EE)
What forms of psychotherapy are available in the NHS?
psychodynamic psychotherapy
CBT
IPT
Family/systemic therapy
Outline the principles of CBT
Cognitive behavioural therapy (CBT) is a type of talking therapy where patients work with a therapist to identify and challenge negative thought patterns and behaviour.
CBT is based on the idea that how we think about situations can affect the way we feel and behave. For example, if you interpret a situation negatively, you might experience negative emotions, which may lead you to act in a certain way.
Give some defence mechanisms recognised in psychoanalysis
repression - forget about it
denial - pretend it never happened
projection - blame someone
displacement - lash out at wrong person
regression - act childlike
sublimation - find another outlet
IAPT was established in England in 2008 to provide more evidence-based talking therapies in primary care. The term “IAPT” stands for:
Improving Access to Psychological Therapies
A 32yr old woman often presents to her GP complaining of low mood. She has been prescribed various antidepressants but has not shown sustained benefit. When distressed in the past she has cut her arms to manage her emotions. She has received counselling at work, which she found helpful, but it has highlighted difficult issues from her childhood which she thinks she might need to address.
She should be referred for an assessment for:
Psychodynamic psychotherapy
Patient with known bipolar disorder is picked up by police during manic episode and placed on a section 136 for assessment. Dr decides he is obviously manic and very disinhibited.
What section of the MHA should be used next ?
Section 3 - admission for treatment because known bipolar disorder
Which SSRI is only recommended in reduced doses in the elderly?
Citalopram - in higher doses is thought to prolong the QT interval which could lead to cardiac arrhythmia
Which of the following blood tests should be routinely monitored within 6 months for patients started on Sodium Valproate?
Liver function tests are recommended before and during the first 6 months of treatment with sodium valproate due to the risks of hepatotoxicity.
Give an example fo a drug which should not be co-prescribed with lithium
aspirin - NSAIDs can increase lithium concentration
What drugs should be avoided in bipolar disorder?
antidepressants - can precipitate mania
What drug can be used to treat depressive episode in bipolar as SSRIs are contraindicated?
lamotrigine
Stevens-Johnson syndrome & toxic epidermal necrolysis are rare side effects of which mood stabilising drug?
lamotrigine
Give 4 differentials for patient presenting hearing voices and delusions that the police are after him:
Paranoid schizophrenia
Schizoaffective disorder
Mania with Psychosis
Drug Induced Psychosis
What drugs could be given IM for rapid tranquillisation?
Lorazepam or Promethazine
You wouldn’t choose to give haloperidol in someone who is antipsychotic naive as a first line.
Under what legislation would you treat a patient with a mental disorder in ED against their will? (who has not yet been sectioned)
the mental capacity act
A patient is detained under a mental health act and is admitted to a psychiatric unit. The patient remains very hostile and aggressive and remains psychotic. He is refusing oral antipsychotics.
What options are available to treat his psychosis?
Depot antipsychotic
Short acting daily injections of antipsychotics
List 5 common side effects of Clozapine
- Hypersalivation
- Weight gain
- Metabolic disturbances
- Sedation
- Constipation
What type of drug is Quetiapine?
List 2 common side effects of this drug.
An atypical antipsychotic
Sedation, weight gain, metabolic changes
What 4 conditions is ECT licensed for?
Severe life threatening depression
Treatment resistant depression
Catatonia
Prolonged Manic episode
Name 2 things other than drugs that can be used to treat depression
exercise regime
CBT
List 4 criteria necessary for using the mental health act:
Having a mental disorder
Of a certain nature Or a certain degree
Risk to health/ safety / risk to others
And community options will not safeguard the risk or are not appropriate
Sangita is a 27 year old woman who presents with her first episode of psychosis. She is extremely worried about gaining weight and does not want to take any medication if it causes weight gain.
What would be an appropriate antipsychotic?
aripiprazole
Sarah is a 39 year old woman on a depot antipsychotic (Zuclopenthixol Decanoate). She has noticed that she has fallen several times recently as a result of a shuffling gait.
Which dopamine pathway is likely to have caused this?
Nigro-striatal
Alan is a 59 year old man who has been found dead at home. He was medically fit and well apart from having Paranoid Schizophrenia treated with Clozapine. The autopsy confirms that Clozapine is the likely cause of death.
What side effect has most likely caused this patients death?
Constipation - biggest cause of death with Clozapine
Mike is a 23 year old man on a psychiatric ward with a diagnosis of Paranoid Schizophrenia. Since his admission 5 days ago he has had multiple IM injections of haloperidol as he is extremely agitated and refusing oral medication.
He now has a fever, and marked muscular rigidity. Staff have noticed that he is tachycardic and his blood pressure is fluctuating from 100/50 to 180/120 within a couple of hours.
What might be the cause of this?
Neuroleptic Malignant Syndrome
A 18 year old female, Josie, attends their GP with her Mum. Her Mum is concerned that Josie has lost a significant amount of weight. What differentials may a GP want to consider in this situation?
*Intentional weight loss (deliberate or eating disorder)
*Depression
*Systemic causes of weight loss e.g. hyperthyroidism, inflammatory bowel disease, infection, malignancy (unlikely in this age group)
The GP suspects that Josie may have an eating disorder. What features are important to enquire about in the history?
*Does she have body image disturbance? i.e. does she think she’s fat despite evidence to the contrary/other opinions.
*How much weight has she lost and over how long?
*Is she restricting calories? If so, how many a day?
*Is she engaging in any behaviours to induce weight loss? E.g. purging, exercising
*Is she taking any medications to aid weight loss? E.g. diuretics, laxatives, amphetamines
*Is she having periods?
What is re-feeding syndrome and what bloods are monitored as part of this?
- Hormonal/electrolyte response on initiation of food after prolonged period of starvation
- Insulin release is increased, leading to phosphate, potassium and magnesium being taken into cells (becoming intracellular) leading to potentially low levels of them in the circulating blood
- U&E’s. Phosphate and Magnesium
NICE recommended tx for anorexia?
Monitoring of weight & dietary counselling
Vitamin and mineral supplementation
Psychological treatment:
CBT-ED
MANTRA (Maudsley Anorexia Nervosa Treatment for Adults)
Specialist Supportive Clinical Management
Admission to hospital if physical health severely compromised
What may be more suggestive of pseudoseizures (or dissociative seizures) on both history and examination than seizures?
Emotional trigger for event e.g. happens during argument
Asynchronous limb movements – often bizarre
Resisting attempts to open eyes
Protective/avoidance behaviour – i.e. patient doesn’t sustain injuries
No post-ictal period (generalised seizure often lengthy recovery), patient able to recall what happened during the actual seizure
Tongue biting and incontinence very rare
Prolonged seizure >3 mins
Testing for what in a blood test may strengthen your belief that this is a pseudoseizure?
Prolactin – this is not diagnostic of a seizure, however prolactin is often released during a seizure and therefore higher levels are detected in the first 2 hours post-seizure. This would not be the case in pseudoseizures.
How is factitious disorder different from malingering?
In factitious disorder a patient will feign symptoms (intentionally) but with no clear secondary gain other than to achieve the sick role and therefore care.
A lady with suspected PP psychosis is demanding that you show her where her real baby is and becoming increasingly distressed. What is the most appropriate next step?
Daytime hours – contact perinatal psychiatry team
Out of hours – contact psychiatry SHO/SPR oncall
All of whom are likely to arrange a mental health act assessment and transfer to a mother and baby bed
What might you want to establish from the notes before visiting and elderly lady who appears manic/delirious?
Review medical records, including when she most recently had any blood tests
Review physical observations chart.
Any known past psychiatric history
Review drug chart
an elderly patient is prescribed: Lansoprazole 30mg OM, Letrozole 2.5mg OM and Dexamethasone 8mg OD.
What are each of these and why might they be prescribed?
Which of these could induce psychosis?
Lansoprazole – PPI (prescribed to help with heartburn caused by steroids)
Dexamethasone – Steroid used in cancer treatment to reduce inflammation/treat cancer itself/reduce immune response
Letrozole – used in hormone dependent breast cancer. An aromatase inhibitor which prevents aromatase changing androgens to oestrogen (thereby reducing oestrogen).
STEROIDS CAN INDUCE PSYCHOSIS
What mood stabilisers are the best adjuvant to tx for depression?
lithium and lamotrigine
What interventions besides drugs can be used for a wide range of MH conditions?
ECT
EMDR
DCS- direct current stimulation
rTMS - Repetitive Transcranial Magnetic Stimulation
Common olfactory hallucination seen in depression?
smelling rotting flesh
Give an example of an anti-hypertensive that is safe to use whilst on lithium
atenolol
lithium is renally excreted so an antihypertensive that does not interfere with the kidneys or the RAAS system is preferable
Dopaminergic inhibition of which part of the brain may cause osteoporosis?
tuberoinfundibular
What therapy may be used for patients with EUPD aside from DBT?
psychodynamic psychotherapy
What is the best antipsychotic to use in depression?
Quetiapine
An alcoholic patient presents with ataxic gait - what supplementation should be given?
parenteral B vitamins
Which drugs can increase lithium levels?
“No ACE in the Hole”
NSAIDS, Ace Inhibitors, and Hydrochlorothiazide
