Psychosis and Schizophrenia Flashcards by Unknown J

Which two theories outline the pathogenesis of Schizophrenia and its subsequent Rx?

DA Theory
• Amphetamine –> Schizophrenia Sx
• D2-receptor agonists –> Similar Symptoms
• Strength of Neuroleptics and D2 antagonist action
• Increased Dopamine content in amygdala (temporal lobe)
• Increased Dopamine content in Striatum of Schizophrenics
Glutamate Theory
• NMDA receptor antagonists (phencyclidine/ketamine) –> psychotic Sx
• Reduced glutamate receptor density and expression –> Schizophrenic brain slices
• TG mice with NMDA receptor expression –> Schizophrenic behaviours
–> Restored with antipsychotics/neuroleptics

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List the 4 Dopamine pathways which are affected in Schizophrenia. What do each do?

Nigrostriatal Pathway (Motor planning of purposeful movement)
Mesolimbic Pathway (+ Mesocortical –> Reward)
Mesocortical Pathway (Working memory/Cognition/Decision making + Mesolimbic –> Reward)
Tuberohypophyseal Pathway (Endocrine function –> PL release)

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List 3 First Generation Antipsychotics.

Chlorpromazine* (D1, D2, a1, H1, mACh, 5-HT2A)
Fluphenazine
Pipotiazine
Haloperidol (D1, D2, a1, H1, 5-HT2A)
Flupentixol (D1, D2, H1, 5-HT2A)
Zuclopenthixol
Chlorpromazine binds all receptors –> Side effects

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List 3 Second Generation Antipsychotics.

Amisulpride (D2 + D3 receptor antagonist)
Clozapine (low D1/low D2/high a1/high H1/mAch/high 5-HT2A)
Olanzapine (unselective receptor blocking)
Risperidone (low D1/high D2/H1/High 5-HT2A)
Paliperidone
Quetiapine (a adrenoceptor blocker)
Aripiprazole (low D1, high D2, a1, H1, 5-HT)

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Which drug would treat positive and negative symptoms?

A. Haloperidol

B. Risperidone

C. Flupentixol

D. Zuclopenthixol

B. Risperidone

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Which drug would treat both positive and negative symptoms?

A. Haloperidol

B. Aripiprazole

C. Chlorpromazine

D. Zuclopenthixol

B. Aripiprazole

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Which drug would least likely cause cause adverse side effects in a patient?

A. Haloperidol

B. Aripiprazole

C. Chlorpromazine

D. Zuclopenthixol

B. Aripiprazole

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Which drug would least likely cause cause adverse side effects in a patient?

A. Haloperidol

B. Risperidone

C. Chlorpromazine

D. Zuclopenthixol

B. Risperidone

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Which drug would least likely cause cause adverse side effects in a patient?

A. Haloperidol

B. Quetiapine

C. Chlorpromazine

D. Zuclopenthixol

B. Quetiapine

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Which drug is the standard second line treatment for resistant Schizophrenia?

A. Haloperidol

B. Risperidone

C. Clozapine

D. Zuclopenthixol

C. Clozapine

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Which drug has high affinity to D1, D2, H1, mACh and 5-HT receptors?

A. Haloperidol

B. Quetiapine

C. Chlorpromazine

D. Zuclopenthixol

C. Chlorpromazine

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Which drug has high affinity to D1, D2, H1, mACh and 5-HT receptors?

A. Haloperidol

B. Quetiapine

C. Clozapine

D. Zuclopenthixol

C. Clozapine

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Which drug is highly selective for the D2 receptor?

A. Haloperidol

B. Aripiprazole

C. Clozapine

D. Zuclopenthixol

B. Aripiprazole

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Which drugs are most likely to have higher chances of metabolic adverse effects?

A. Haloperidol

B. Quetiapine

C. Clozapine

D. Zuclopenthixol

B. Quetiapine

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Which drugs are most likely to have higher chances of metabolic adverse effects?

A. Haloperidol

B. Olanzapine

C. Clozapine

D. Zuclopenthixol

B. Olanzapine

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What is Neuroleptic Malignant Syndrome?

List 5 Symptoms.

Rare condition occurring in early stage of treatment with antipsychotic drugs whereby treatment is supportive

Hyperthermia
∆ consciousness
Muscle rigidity
Pallor
Tachycardia
Labile blood pressure
Sweating
Urinary incontinence
Elevated Creatinine Phosphokinase (CPK) level

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List 5 ASEs of Lithium

Fine tremor
Dry mouth
Altered taste
Increased thirst
Increased urination
Nausea
Weight gain
ECG ∆s
Goitre
Hypothyroidism
Hyperparathyroidsm
Hypercalcemia
Leukocytosis
Increased Weight/Dryness
Taste/Thirst (Nephrogenic Diabetes Insipidus)
Hypothyroidism/Hyperparathyroidism/Hypercalcemia
Increased Urine Output (Polyuria)
Movement/Memory change

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List 5 clinical features of Lithium toxicity.

Vomiting
Diarrhoea
Coarse tremor (large movements)
Muscle weakness
Ataxia
Slurred speech
Blurred vision
Lethargy
Confusion
Seizures

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In neuroleptics, what system is affected to elicit the side effect of Galactorrhoea and Gynecomastia?

A. D2 (mesocortical)

B. H1

C. mACh

D. D2 (Tuberohypophyseal)

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In neuroleptics, what system is affected to elicit the side effect of Amenorrhoea?

A. D2 (mesocortical)

B. H1

C. mACh

D. D2 (Tuberohypophyseal)

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In neuroleptics, what system is affected to elicit the side effect of Tardive Dyskinesia?

A. D2 (mesocortical)

B. D2 (nigrostriatal)

C. mACh

D. D2 (Tuberohypophyseal)

B. D2 (nigrostriatal)

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In neuroleptics, what system is affected to elicit the side effects of salivation and lacrimation?

A. D2 (mesocortical)

B. D2 (nigrostriatal)

C. mACh

D. D2 (Tuberohypophyseal)

C. mACh

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In neuroleptics, what system is affected to elicit the side effects of urinary retention and diaphoresis?

A. D2 (mesocortical)

B. H1

C. mACh

D. D2 (Tuberohypophyseal)

C. mACh

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In neuroleptics, what system is affected to elicit the side effects of Emesis and GI upset?

A. D2 (mesocortical)

B. H1

C. mACh

D. D2 (Tuberohypophyseal)

C. mACh

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In neuroleptics, what system is affected to elicit the side effects of postural hypotension? A. D2 (mesocortical) B. H1 C. mACh D. a1

D. a1

In neuroleptics, what system is affected to elicit the side effects of sedation? A. D2 (mesocortical) B. H1 C. mACh D. a1

B. H1

In neuroleptics, what system is affected to elicit the side effects of anti-emesis? A. D2 (mesocortical) B. H1 C. mACh D. a1

B. H1

Antagonism of the a1 receptor by neuroleptics causes which of the following side effects? A. Weight gain B. Sedation C. Postural Hypotension D. Jaundice

C. Postural Hypertension

Antagonism of the D2 receptor in the mesolimbic system by neuroleptics causes which of the following side effects? A. Weight gain B. Sedation C. Postural Hypotension D. Jaundice

A. Weight gain

Antagonism of the D2 receptor in the nigrostriatal pathway by neuroleptics causes which of the following side effects? A. Weight gain B. Parkinsonian-like symptoms C. Postural Hypotension D. Apathy

B. Parkinsonian-like symptoms

Antagonism of the H1 receptor by neuroleptics causes which of the following side effects? A. Weight gain B. Sedation C. Postural Hypotension D. Apathy

B. Sedation

Antagonism of the H1 receptor by neuroleptics causes which of the following side effects? A. Weight gain B. Anti-emesis C. Postural Hypotension D. Apathy

B. Anti-emesis

Antagonism of the mAch receptor by neuroleptics causes which of the following side effects? A. Weight gain B. Anti-emesis C. Salivation D. Mydriasis

C. Salivation

Antagonism of the mAch receptor by neuroleptics causes which of the following side effects? A. Weight gain B. Anti-emesis C. Lacrimation D. Meiosis

C. Lacrimation

Antagonism of the mAch receptor by neuroleptics causes which of the following side effects? A. Weight gain B. Tachycardia C. Urinary retention D. Meiosis

C. Urinary retention

List two Neuroleptic medications that give you the highest risk of weight gain and diabetes.

Clozapine Olanzapine

Which neuroleptic medication has the fewest side effects generally?

Aripiprazole

A patient has been put on Aripiprazole following his 1st episode of Schizophrenia. After 6-8 weeks the medication is not effective. The change of medication to Risperidone is ineffective. What should the doctor do now? A. Change to haloperidol B. Change dose of Risperidone C. Place patient on Clozapine D. Continue at the same dose, on the same regimen

C. Place patient on Clozapine

A patient has been put on Aripiprazole following his 1st episode of Schizophrenia. After 6-8 weds the medication is not effective. The change of medication to Risperidone is ineffective. His Schizophrenia worsens and there are substantiated concerns over his compliance which have been ongoing. What should the doctor do now? A. Ask the patient to kindly take the medication B. Use a CTO to ensure the patient is on a depot/compliance aid C. Tell the patient he needs to comply or he will be placed in hospital care D. Give him a drug he asks for

B. Use a CTO to ensure the patient is on a depot/compliance aid

In an acute behavioural emergency, which drug would you most likely administer? A. Risperidone B. Onlazipine C. Clonazine D. Chlorpromazine

D. Chlorpromazine

In an acute behavioural emergency, which drug would you most likely administer? A. Risperidone B. Onlazipine C. Clonazine D. Haloperidol

D. Haloperidol

In Schizophrenia with Depression, which drug would you most likely administer? A. Risperidone B. Onlazipine C. Flupentixol D. Haloperidol

C. Flupentixol

In the treatment of emesis in a Schizophrenic patient, which drug would you most likely administer? A. Metoclopramide B. Onlazipine C. Prochlorperazine D. Haloperidol

C. Prochlorperazine

What is psychosis?

Disorder whereby patient loses contact with external reality, associated with abnormal functioning of frontal and temporal lobes and disorganised thoughts and actions

List a 2 primary and 2 secondary diseases with Psychosis.

``` 1º Psychotic Disorders • Schizophrenia • Bipolar disorder • Schizoaffective disorder • Persistent delusional disorders • Schizophreniform psychosis (Significant Sx for 1 month-6 months; 1 month ≤ Sx < 6 months ``` 2º Psychotic Disorders • Drug/Toxin exposure/Recreational drugs/Organophosphates • Trauma (TBI) • Delirium • Brain tumour • Steroids (high dose) • Lead and Mercury • Cannabis/ Mushrooms/ Speeed/ LSD • Organophosphates • Infection (encephalitis) • Delirium (overlap with underlying dementia) • Vitamin Deficiency: Vitamin B12/Vitamin B1/Vitamin B3 • Endocrine disorders: Hyperparathyroidism/Cushing’s (excess cortisol) • Metabolic disorders • Chromosomal disorders: PWS/Klinefelter’s

What is Schizophrenia?

MHD characterised by co-occurrence of: delusions, hallucinations, disorganised speech, catatonic/disorganised behaviour or negative symptoms (anhedonia/affective flattening/avolition/cognitive deficit or alogia) occurring for significant proportion of 1 month period (active phase), associated with continuous problems over ≥ 6 month period.

Outline the Aetiology of Schizophrenia.

``` ‘Stress Diathesis’ --> Vulnerability (Diathesis) + Stressors ≈ Sx • Loss • Trauma • Infection • Substance misuse ```

List 3 Risk Factors for Schizophrenia.

* FHx Schizophrenia * ACE * Minority position * Family environment * Social class * Substance misuse * Disease: Infection/Chronic

What percentage of people experiencing their first episode of Schizophrenia recover after their 1st episode? A. 10% B. 20% C. 80% D. 70%

B. 20%

Outline the pathophysiology of Schizophrenia.

Imbalance of NTs (DA/5-HT/Glu) --> Hyperdopaminergic in mesolimbic tract + Excitotoxicity ≈ long-term deterioration of glutamate neurones at hippocampus • Cerebral atrophy • Enlarged lateral and third ventricular volume • Reduced volume of Subcortical structures (cerebellum; caudate; thalamic) • Reduced activity of prefrontal cortex (reduced P300 event-related potential)

List the clinical features of Schizophrenia.

DSM-5 2 Sx lasting predominantly 1 month and over 6 months present  1 Positive required = THREAD LESS • Delusions (unshakeable beliefs): Persecutory/Grandiose/Nihilistic or Religious • Auditory hallucinations (seeing something not real): (command/derogatory/conversing/running commentaries) • Disorganised/catatonic behaviour • Tangentiality (going off on a tangent) ± Derailment (gradient of changing topic) • Verbigeration (repetition of words)/Thought echo + • Avolition (demotivation) • Anhedonia (loss of enjoyment) • Asocial behaviour (loss of social drive) • Affective blunting (diminished expression of feeling) • Alogia (reduced speech quality and quantity) • Cognitive deficit (attention/language/memory/executive function/abstract thinking) • Somatisation (expressed in the body – physical Sx)

Which of the following would constitute a diagnosis of Schizophrenia? A. Delusions + Hallucinations for 1 week B. Delusions + Hallucinations for 2 weeks C. Delusions + Avolition for the majority of a month and present over 6 months D. Avolition and Alogia for the majority of a month and present over 6 months

C. Delusions + Avolition for the majority of a month and present over 6 months

List the clinical features of Schizophrenia.

Mnemonic: THREAD LESS ``` Tangentiality Hallucinations (auditory/visual) Reduced reality (Delusions)/Repetition of words (Verbigeration) Emotional control: Incongruous effect? Arousal Disorganised/ Catatonic Behaviour ``` ``` Loss of volition/social settings Emotional flatness (Affective Blunting) Speech reduced (Alogia) Slowness in thought (cognitive deficit) ```

What is the first line treatment for Schizophrenia? A. Haloperidol B. Clozapine C. Prochloperazine D. Aripiprazole

D. Aripiprazole

What is the first line treatment for Schizophrenia? A. Haloperidol B. Clozapine C. Prochloperazine D. Risperidone

D. Risperidone

What is the first line treatment for Schizophrenia? A. Haloperidol B. Clozapine C. Prochloperazine D. Quetiapine

D. Quetiapine

What is the correct dose of Aripiprazole? A. 10-15mg PO BD B. 10-15mg PO OD C. 1mg PO BD D. 1mg PO OD

B. 10-15mg PO OD

What is the correct dose of Risperidone? A. 10-15mg PO BD B. 10-15mg PO OD C. 1mg PO BD D. 1mg PO OD

C. 1mg PO BD

What is the correct dose of Quetiapine? A. 25mg PO BD B. 25mg PO OD C. 10-15mg PO BD D. 10-15mg PO OD

A. 25mg PO BD

What is the correct dose of Fluoxetine? A. 20mg PO BD B. 25mg PO OD C. 10-15mg PO BD D. 10-15mg PO OD

B. 25mg PO OD

What is the dose for Lithium as an anti-Manic drug? A. 300mg BDS-TDS B. 300mg QDS C. 200mg PO BDS D. 200mg PO OD

A. 300mg BDS-TDS

What is the dose for Carbamazepine as an anti-Manic drug? A. 300mg BDS-TDS B. 300mg QDS C. 200mg PO BDS D. 200mg PO OD

C. 200mg PO BDS

What is the first line treatment for Schizophrenia? A. Haloperidol B. Clozapine C. Prochloperazine D. Quetiapine

B. Clozapine

Which of the following statements are true? A. SGA neuroleptics treat positive symptoms only B. FGA neuroleptics treat negative symptoms only C. FGA neuroleptics treat positive and negative symptoms D. SGA neuroleptics treat positive and negative symptoms

D. SGA neuroleptics treat positive and negative symptoms

What is Schizoaffective Disorder?

Illness defined by course combining affective and psychotic symptoms with presence of schizophrenia Sx concurrent with mood symptom (depression or mania) lasting for the majority of a 1-month period

John, a 25 year old Engineering student presents with delusions of Grandeur almost every day for the past 3 weeks. Additionally, he says that in the last few months people have lost interest when he speaks, he keeps losing track and sometimes repeating his words. He says he had felt demotivated in the last 6 months and become less social. He says his mood has been relatively stable and he is not depressed. What is your DDx? A. Schizoaffective Disorder B. Schizophrenia C. Bipolar Disorder D. Mania

B. Schizophrenia

John, a 25 year old Engineering student presents with delusions of Grandeur almost every day for the past 3 weeks. Additionally, he says that in the last few months people have lost interest when he speaks, he keeps losing track and sometimes repeating his words. He says he had felt demotivated in the last 6 months and become less social. He says his mood has been relatively stable and he is not depressed. In his personal history, he says he was previously sexually abused as a chid by his step-Uncle, had a father who was an alcoholic and his mother suffered from Schizophrenia. List his clinical features and give your DDx.

- Delusions - Tangentiality ± derailment - Verbigeration - Avolition - Asocial behaviour DDx: Schizophrenia

John, a 25 year old Engineering student presents with delusions of Grandeur almost every day for the past 3 weeks. Additionally, he says that in the last few months people have lost interest when he speaks, he keeps losing track and sometimes repeating his words. He says he had felt demotivated in the last 6 months and become less social. He says his mood has been relatively stable and he is not depressed. In his personal history, he says he was previously sexually abused as a chid by his step-Uncle, had a father who was an alcoholic and his mother suffered from Schizophrenia. What are his risk factors?

- ACE: Sexual abuse - ACE: Alcoholism - ACE: Mental health of mother - FHx Schizophrenia

John, a 25 year old Engineering student presents with delusions of Grandeur almost every day for the past 3 weeks. Additionally, he says that in the last few months people have lost interest when he speaks, he keeps losing track and sometimes repeating his words. He says he had felt demotivated in the last 6 months and become less social. He says his mood has been relatively stable and he is not depressed. In his personal history, he says he was previously sexually abused as a chid by his step-Uncle, had a father who was an alcoholic and his mother suffered from Schizophrenia. What is your first line treatment for John?

• Aripiprazole (10-15mg PO OD)/Risperidone (1mg PO BD)/ Quetiapine (25mg PO BD) + (adjunct) • Psychotherapy: CBT

List 3 RFs of Schizoaffective Disorder.

* FHx Schizophrenia * Substance use * ACEs

List the types of Schizoaffective disorder.

* Mania Type: Mania Sx present | * Depressive Type: Depressive Sx present

James, a 19 year old College student studying Business presents with delusions which he says he has experienced for the best part of 3 weeks. He says he cannot stop the belief that someone is messing with his hair. Every time he goes to do it, a strand comes undone and he is certain its his next door neighbour who always laughs at his hair. He says he has become less social, he has been less motivated for the past year, frequently flunking his GCSE Maths exam. The continual failing of this exam has led to him experiencing anhedonia, persistent low mood and irritability. He says he does not take any over the counter medication but is a regular smoker of Cannabis with occasional LSD use. His mother has been diagnosed with Anxiety, his father is an Alcoholic and was also abusive when they were younger. What is your DDx? A. Schizoaffective Disorder B. Schizophrenia C. Bipolar Disorder D. Mania

A. Schizoaffective Disorder

James, a 19 year old College student studying Business presents with delusions which he says he has experienced for the best part of 3 weeks. He says he cannot stop the belief that someone is messing with his hair. Every time he goes to do it, a strand comes undone and he is certain its his next door neighbour who always laughs at his hair. He says he has become less social, he has been less motivated for the past year, frequently flunking his GCSE Maths exam. The continual failing of this exam has led to him experiencing anhedonia, persistent low mood and irritability. He says he does not take any over the counter medication but is a regular smoker of Cannabis with occasional LSD use. His mother has been diagnosed with Anxiety, his father is an Alcoholic and was also abusive when they were younger. What is your first line treatment for James in acute care? A. Haloperidol + Fluoxetine B. C. Aripiprazole + Diazepam + Fluoxetine C. Aripiprazole + Lorazepam + Fluoxetine D. Aripiprazole + Lithium + Lorazepam

C. Aripiprazole + Lorazepam + Fluoxetine

James, a 19 year old College student studying Business presents with delusions which he says he has experienced for the best part of 3 weeks. He says he cannot stop the belief that someone is messing with his hair. Every time he goes to do it, a strand comes undone and he is certain its his next door neighbour who always laughs at his hair. He says he has become less social, he has been less motivated for the past year, frequently flunking his GCSE Maths exam. The continual failing of this exam has led to him experiencing anhedonia, persistent low mood and irritability. He says he does not take any over the counter medication but is a regular smoker of Cannabis with occasional LSD use. His mother has been diagnosed with Anxiety, his father is an Alcoholic and was also abusive when they were younger. Following a failed attempt on Aripiprazole and Risperidone, what is the next line treatment for James in acute care? A. Haloperidol + Fluoxetine B. Clozapine + Sertraline + Lorazepam C. Aripiprazole + Lorazepam + Fluoxetine D. Aripiprazole + Lithium + Lorazepam

B. Clozapine + Sertraline + Lorazepam

James, a 19 year old College student studying Business presents with delusions which he says he has experienced for the best part of 3 weeks. He says he cannot stop the belief that someone is messing with his hair. Every time he goes to do it, a strand comes undone and he is certain its his next door neighbour who always laughs at his hair. He says he has become less social, he has been less motivated for the past year, frequently flunking his GCSE Maths exam. The continual failing of this exam has led to him experiencing anhedonia, persistent low mood and irritability. He says he does not take any over the counter medication but is a regular smoker of Cannabis with occasional LSD use. His mother has been diagnosed with Anxiety, his father is an Alcoholic and was also abusive when they were younger. What is your first line treatment for James' ongoing care? A. Haloperidol + Fluoxetine B. Aripiprazole + Diazepam + Fluoxetine C. Aripiprazole + Lorazepam + Fluoxetine D. Aripiprazole + Lithium + Lorazepam

B. Aripiprazole + Diazepam + Fluoxetine

Should clozapine fail, what is the next line neuroleptic drug in the treatment of Resistant Schizoaffective Disorder?

Haloperidol

What is brief psychotic disorder?

Ellie, a 28 year old Lawyer presents with delusions of a persecutory nature. She believes her husband is going through a mental health disease when he is utterly supportive and kind. These delusions have only been occurring for the past 3 days but her husband is incredibly worried she may be a threat to him and their newborn child. In addition to this, she has displayed less feeling (affective blunting) with diminished speech quality (alogia). What is your Differential diagnosis? A. Schizophrenia B. Schizoaffective disorder C. Brief Psychotic Disorder D. Bipolar Disorder

C. Brief Psychotic Disorder

Ellie, a 28 year old Lawyer presents with delusions of a persecutory nature. She believes her husband is going through a mental health disease when he is utterly supportive and kind. These delusions have only been occurring for the past 3 days but her husband is incredibly worried she may be a threat to him and their newborn child. In addition to this, she has displayed less feeling (affective blunting) with diminished speech quality (alogia). How would you manage this patient acutely? A. Aripiprazole + Diazepam B. Aripiprazole + Diazepam + Lithium C. Aripiprazole + Lorazepam D. Clozapine

C. Aripiprazole + Lorazepam

Ellie, a 28 year old Lawyer presents with delusions of a persecutory nature. She believes her husband is going through a mental health disease when he is utterly supportive and kind. These delusions have only been occurring for the past 3 days but her husband is incredibly worried she may be a threat to him and their newborn child. In addition to this, she has displayed less feeling (affective blunting) with diminished speech quality (alogia). How would you manage this patient in their ongoing treatment? A. Aripiprazole + Diazepam B. Aripiprazole + Diazepam + Lithium C. Aripiprazole + Lorazepam D. Clozapine

A. Aripiprazole + Diazepam

What is Bipolar disorder?

Psychiatric diagnosis of 1 ≤ manic or mixed episodes followed by hypomanic or major depressive episodes featuring: grandiosity/hypersomnolence/pressured speech/flight of ideas/distractibility/risk-taking behaviour (loss of inhibition)

Give 3 Risk Factors for Bipolar Disorder.

* Early age of mood disorder onset * FHx BPD/Suicide * Poor response to antidepressants * Highly recurrent mood episodes * Comorbid anxiety * Substance misuse * Psychosocial instability

D. Bipolar Disorder

Ellie, a 28 year old Lawyer presents with delusions of a persecutory nature. She believes that Lawyers are far superior, empathetic and kinder than Doctors and that Doctors are trying to Euthanise the world. She also has experienced tremendous drive to sleep and reduced concentration at work. Finally, this happens in episodes she says, and during these episodes of altered behaviour, they are terrible but resolve after about a week. During these episodes, she notices she tends to lose a lot of money and is currently anxious as she last took out £300 in Wonga loans which she is struggling to pay back. What is your Treatment? A. ECT B. Aripiprazole (10-15mg PO OD) + Lithium (300mg BDS-TDS) C. Aripiprazole (10-15mg PO OD) + Clonazepam (1mg/day in 2-3 doses) D. Clozapine

C. Aripiprazole (10-15mg PO OD) + Clonazepam (1mg/day in 2-3 doses)

Ellie, a 28 year old Lawyer presents with delusions of a persecutory nature. She believes that Lawyers are far superior, empathetic and kinder than Doctors and that Doctors are trying to Euthanise the world. She also has experienced tremendous drive to sleep and reduced concentration at work. Finally, this happens in episodes she says, and during these episodes of altered behaviour, they are terrible but resolve after about a week. During these episodes, she notices she tends to lose a lot of money and is currently anxious as she last took out £300 in Wonga loans which she is struggling to pay back. She has previously been treated with Aripiprazole (15mg PO OD) and Lithium (300mg BDS) but her episodes are becoming more severe. What is your Treatment? A. ECT B. Aripiprazole (10-15mg PO OD) + Lithium (300mg BDS-TDS) + Clonazepam (1mg/day in 2-3 doses) C. Aripiprazole (10-15mg PO OD) + Clonazepam (1mg/day in 2-3 doses) D. Clozapine

B. Aripiprazole (10-15mg PO OD) + Lithium (300mg BDS-TDS) + Clonazepam (1mg/day in 2-3 doses)

Ellie, a 28 year old Lawyer presents with delusions of a persecutory nature. She believes that Lawyers are far superior, empathetic and kinder than Doctors and that Doctors are trying to Euthanise the world. She also has experienced tremendous drive to sleep and reduced concentration at work. Finally, this happens in episodes she says, and during these episodes of altered behaviour, they are terrible but resolve after about a week. During these episodes, she notices she tends to lose a lot of money and is currently anxious as she last took out £300 in Wonga loans which she is struggling to pay back. She has previously been treated with Aripiprazole (15mg PO OD) and Lithium (300mg BDS), the episodes are remaining the same so she is asking what might achieve symptomatic control? What is your Treatment? A. CBT B. Aripiprazole (10-15mg PO OD) + Lithium (300mg BDS-TDS) + Clonazepam (1mg/day in 2-3 doses) C. Aripiprazole (10-15mg PO OD) + Clonazepam (1mg/day in 2-3 doses) D. Clozapine

D. Clozapine

Ellie, a 28 year old Lawyer presents with delusions of a persecutory nature. She believes that Lawyers are far superior, empathetic and kinder than Doctors and that Doctors are trying to Euthanise the world. She also has experienced tremendous drive to sleep and reduced concentration at work. Finally, this happens in episodes she says, and during these episodes of altered behaviour, they are terrible but resolve after about a week. During these episodes, she notices she tends to lose a lot of money and is currently anxious as she last took out £300 in Wonga loans which she is struggling to pay back. She has previously been treated with Aripiprazole (15mg PO OD) and Lithium (300mg BDS), the episodes are remaining the same so she is asking what might achieve symptomatic control? What is your Treatment? A. CBT + Aripiprazole (10-15mg PO OD) + Lithium (300mg BDS-TDS) + Clonazepam (1mg/day in 2-3 doses) B. Aripiprazole (10-15mg PO OD) + Lithium (300mg BDS-TDS) + Clonazepam (1mg/day in 2-3 doses) C. Aripiprazole (10-15mg PO OD) + Clonazepam (1mg/day in 2-3 doses) D. ECT

D. ECT

WHICH OF THE FOLLOWING STATEMENTS ABOUT THE PROGNOSIS FOR PEOPLE WITH PSYCHOSIS IS CORRECT? A. OF PEOPLE EXPERIENCING THEIR FIRST EPISODE OF PSYCHOSIS, 80% WILL RECOVER AND EXPERIENCE NO FURTHER EPISODES B. PEOPLE WITH PSYCHOSIS AND SCHIZOPHRENIA DIE ON AVERAGE FIVE TO 10 YEARS EARLIER THAN THE GENERAL POPULATION C. FOR PEOPLE EXPERIENCING SEVERE MENTAL ILLNESS CARDIOVASCULAR DISEASE IS A BIGGER CONTRIBUTOR TO REDUCED LIFE EXPECTANCY THAN SUICIDE

C. FOR PEOPLE EXPERIENCING SEVERE MENTAL ILLNESS CARDIOVASCULAR DISEASE IS A BIGGER CONTRIBUTOR TO REDUCED LIFE EXPECTANCY THAN SUICIDE

A 22 YEAR OLD WOMAN COMES TO SEE YOU AFTER HER FIRST EPISODE OF PSYCHOSIS WANTING TO KNOW MORE ABOUT THE SIDE EFFECTS OF HER ANTIPSYCHOTIC MEDICATION. WHICH OF THE FOLLOWING STATEMENTS IS CORRECT? A. TWENTY-FIVE PERCENT OF PATIENTS WITH A FIRST EPISODE OF PSYCHOSIS CAN EXPECT TO GAIN MORE THAN 7% OF THEIR BODY WEIGHT ON AVERAGE WITHIN THE FIRST YEAR OF TREATMENT B. PEOPLE CAN DEVELOP DIABETES WITHIN WEEKS OF STARTING ANTIPSYCHOTICS AND THIS CAN REVERSE ON STOPPING THE DRUG C. LIPID DISTURBANCES ARE RARE DURING THE FIRST FEW YEARS OF TREATMENT D. OLDER PATIENTS ARE MORE SUSCEPTIBLE TO ANTIPSYCHOTIC INDUCED WEIGHT GAIN AND METABOLIC DISTURBANCE THAN YOUNGER PATIENTS

B. PEOPLE CAN DEVELOP DIABETES WITHIN WEEKS OF STARTING ANTIPSYCHOTICS AND THIS CAN REVERSE ON STOPPING THE DRUG

WHICH OF THE FOLLOWING STATEMENTS ABOUT PEOPLE WITH PSYCHOSIS WHO ARE TREATED BY AN EIP SERVICE COMPARED WITH A TRADITIONAL COMMUNITY MENTAL HEALTH SERVICE IS CORRECT? A. THEY ARE MORE LIKELY TO REQUIRE HOSPITAL ADMISSION B. THEY ARE LESS LIKELY TO BE IN EMPLOYMENT C. THEY RECEIVE COST EFFECTIVE SERVICES THAT CAN RETURN NHS SAVINGS WITHIN THE FIRST YEAR OF TREATMENT D. THEY AND THEIR FAMILIES PREFER COMMUNITY MENTAL HEALTH SERVICES

C. THEY RECEIVE COST EFFECTIVE SERVICES THAT CAN RETURN NHS SAVINGS WITHIN THE FIRST YEAR OF TREATMENT

WHICH ONE OF THE FOLLOWING STATEMENTS ABOUT PEOPLE WITH SEVERE MENTAL ILLNESS WHO SMOKE IS CORRECT? A. THEY CAN SPEND UP TO 10% OF THEIR DISPOSABLE INCOME ON CIGARETTES B. SMOKING CESSATION INTERVENTIONS THAT ARE EFFECTIVE FOR THE GENERAL POPULATION ARE LESS EFFECTIVE FOR THIS POPULATION C. THIRTY PERCENT OF YOUNG PEOPLE EXPERIENCING THEIR FIRST EPISODE OF PSYCHOSIS ARE ALREADY SMOKING REGULARLY D. THE DOSAGE OF ANTIPSYCHOTIC MEDICATION MAY NEED TO BE REDUCED BY 25% WITHIN A WEEK OF SMOKING CESSATION TO AVOID DRUG TOXICITY

D. THE DOSAGE OF ANTIPSYCHOTIC MEDICATION MAY NEED TO BE REDUCED BY 25% WITHIN A WEEK OF SMOKING CESSATION TO AVOID DRUG TOXICITY

A 40 YEAR OLD MAN WHO HAS EXPERIENCED SCHIZOPHRENIA FOR OVER 10 YEARS COMES TO SEE YOU FOR HIS ANNUAL PHYSICAL HEALTH CHECK. WHICH OF THE FOLLOWING STATEMENTS ABOUT HIS HEALTH COMPARED WITH HIS PEERS WITHOUT MENTAL ILLNESS IS CORRECT? A. HE HAS FIVE TIMES THE RISK OF HAVING METABOLIC SYNDROME B. HE HAS A TWO TO THREE TIMES GREATER LIFETIME RISK OF DEVELOPING DIABETES C. HE IS TWICE AS LIKELY TO HAVE ABNORMAL LIPIDS D. HE IS NO MORE LIKELY TO BE HYPERTENSIVE

B. HE HAS A TWO TO THREE TIMES GREATER LIFETIME RISK OF DEVELOPING DIABETES AT THE ONSET OF PSYCHOSIS, METABOLIC SYNDROME OCCURS WITH SIMILAR FREQUENCY TO THE GENERAL POPULATION, BUT BY THE AGE OF 40 IT HAS BECOME FOUR TIMES MORE COMMON IN PATIENTS WITH PSYCHOSIS

REGARDING VENLAFAXINE, WHICH OF THE FOLLOWING STATEMENTS IS CORRECT? A. IT CAN BE GIVEN TO PATIENTS WHO HAVE RECENTLY HAD A MYOCARDIAL INFARCTION B. IT IS MORE LIKELY TO CAUSE SIDE EFFECTS THAN SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) C. IT MAY CAUSE A REDUCTION IN BLOOD PRESSURE

B. IT IS MORE LIKELY TO CAUSE SIDE EFFECTS THAN SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) CONTRAINDICATED AFTER RECENT MI – MAT CAUSE RISE IN BP

YOU SEE A 35 YEAR OLD WOMAN WITH DEPRESSION. SHE HAS BEEN TAKING CITALOPRAM FOR ONE YEAR. YOU HALVED HER DOSE OF CITALOPRAM TWO WEEKS AGO. SINCE THEN SHE HAS BEEN EXPERIENCING LETHARGY AND HER MOOD IS WORSENING. WHAT SHOULD YOU SUGGEST? A. INCREASE CITALOPRAM TO THE ORIGINAL DOSE AND REDUCE IT MORE GRADUALLY B. CHANGE HER MEDICATION TO PAROXETINE

A. INCREASE CITALOPRAM TO THE ORIGINAL DOSE AND REDUCE IT MORE GRADUALLY SHE MAY BE EXPERIENCING WITHDRAWAL EFFECTS, BUT THIS IS POTENTIALLY A WORSE PROBLEM WITH PAROXETINE

YOU SEE A 30 YEAR OLD WOMAN WITH MILD DEPRESSION. SHE WOULD LIKE TO TRY ST JOHN'S WORT. SHE ALSO TAKES A COMBINED ORAL CONTRACEPTIVE. WHAT SHOULD YOU ADVISE HER? A. IT DOES NOT INTERACT WITH THE CONTRACEPTIVE PILL B. IT MAY REDUCE THE EFFECTIVENESS OF HER CONTRACEPTIVE PILL C. SHE SHOULD TAKE IT IN HIGH DOSES

B. IT MAY REDUCE THE EFFECTIVENESS OF HER CONTRACEPTIVE PILL IT POTENTIALLY REDUCES THE CONCENTRATION OF THE COCP PROBABLY BY INDUCING LIVER ENZYMES

YOU SEE A 45 YEAR OLD WOMAN WHO IS TAKING CHLORPROMAZINE FOR SCHIZOPHRENIA. SHE DEVELOPED A RASH OVER HER BODY AFTER SUNBATHING. HER SCHIZOPHRENIA IS WELL CONTROLLED. WHAT SHOULD YOU DO? A. STOP CHLORPROMAZINE B. CHANGE THE CHLORPROMAZINE TO OLANZAPINE C. ADVISE HER TO USE SUNBLOCK AND AVOID SUNBATHING

C. ADVISE HER TO USE SUNBLOCK AND AVOID SUNBATHING CHLORPROMAZINE CAN CAUSE A PHOTOSENSITIVE RASH

REGARDING NEUROLEPTIC MALIGNANT SYNDROME, WHICH OF THE FOLLOWING STATEMENTS IS CORRECT? A. IT USUALLY OCCURS WHEN REDUCING ANTIPSYCHOTIC MEDICATION B. IT CAN LEAD TO DEATH C. IT USUALLY OCCURS IN PATIENTS WHO TAKE ATYPICAL ANTIPSYCHOTIC DRUGS

B. IT CAN LEAD TO DEATH USUALLY OCCURS WHEN COMMENCING TREATMENT OR INCREASING DOSE BUT CAN OCCUR WITH AN ABRUPT WITHDRAWAL

A 40 YEAR OLD MAN COMES TO SEE YOU BECAUSE HE FEELS UNWELL AND DEPRESSED. HE HAS A DIARRHOEAL ILLNESS. ON EXAMINATION HIS SPEECH IS SLURRED AND HE HAS A COARSE TREMOR. HIS WIFE SAYS THAT HE HAS BEEN DROWSY RECENTLY. HE IS NOT YOUR USUAL PATIENT AND HIS NOTES ARE NOT IMMEDIATELY AVAILABLE. HIS WIFE SAYS THAT HE HAS A HISTORY OF BIPOLAR DISORDER. WHAT IS THE MOST IMPORTANT DIAGNOSIS TO CONSIDER? A. HYPOTHYROIDISM B. DEPRESSION C. LITHIUM TOXICITY D. PARKINSON’S DISEASE

C. LITHIUM TOXICITY THESE ARE POTENTIAL; SYMPTOMS OF LITHIUM TOXICITY

A 28 YEAR OLD WOMAN HAS HAD BIPOLAR DISORDER FOR FOUR YEARS. SHE HAS BEEN WELL FOR THE PAST TWO YEARS. SHE COMES TO SEE YOU BECAUSE SHE THINKS SHE IS PREGNANT. A TEST CONFIRMS HER SUSPICIONS. THE PREGNANCY IS UNPLANNED. SHE IS CURRENTLY STABLE AND NOT ON TREATMENT. SHOULD SHE NEED TREATMENT DURING HER PREGNANCY WHICH OF THE FOLLOWING IS LEAST DANGEROUS IN HER CIRCUMSTANCE? A. CARBAMAZEPINE B. VALPROATE C. LITHIUM D. AN ANTIPSYCHOTIC E. LAMOTRIGINE

D. AN ANTIPSYCHOTIC NICE RECOMMENDS SWITCHING TO AN ANTIPSYCHOTIC DURING PREGNANCY

A MOTHER BRINGS HER 25 YEAR OLD SON TO SEE YOU. HE HAS RECENTLY BEEN DIAGNOSED WITH SCHIZOPHRENIA AND BEEN TAKING FLUPENTIXOL FOR THE LAST TWO WEEKS. OVER THE LAST DAY HE HAS BECOME CONFUSED AND HAD TWO EPISODES OF INCONTINENCE. ON EXAMINATION HE IS CONFUSED AND DROWSY. HIS TEMPERATURE IS 38°C, HIS HEART RATE IS 110 BEATS PER MINUTE AND HIS BLOOD PRESSURE IS 160/100 MM HG. WHAT SHOULD YOU DO? A. REQUEST A URINE CULTURE AND START ANTIBIOTICS B. STOP THE DRUG AND REFER HIM IMMEDIATELY TO HOSPITAL C. REDUCE THE DOSE OF MEDICATION AND ARRANGE AN URGENT OUTPATIENT APPOINTMENT WITH THE PSYCHIATRIST

B. STOP THE DRUG AND REFER HIM IMMEDIATELY TO HOSPITAL THIS COULD BE NEUROLEPTIC MALIGNANT SYNDROME

NAME 5 SYMPTOMS COMPATIBLE WITH SCHIZOPHRENIA

``` POSITIVE SYMPTOMS SUCH AS: HALLUCINATIONS DELUSIONS DISORGANIZED SPEECH DISORGANIZED/CATATONIC BEHAVIOUR ``` ``` NEGATIVE SYMPTOMS SUCH AS : EMOTIONAL APATHY LACK OF DRIVE POVERTY OF SPEECH SOCIAL WITHDRAWAL SELF NEGLECT. ```

NAME 3 RECREATIONAL DRUGS THAT CAN INDUCE PSYCHOSIS

``` COCAINE CANNABIS AMPHETAMINES PHENCYCLIDINE ALCOHOL INHALANTS (SOLVENTS, AEROSOLS, GASES, NITRITES). ```

NAME A) A FIRST GENERATION ANTI-PSYCHOTICS B) A SECOND GENERATION ANTI-PSYCHOTICS

HALOPERIDOL, CHLORPROMAZINE, PROMAZINE, FLUPHANZINE/ PROCHLORPERAZINE QUETIAPINE, RISPERIDONE, ARIPIPRAZOLE, OLANZAPINE/ CLOZAPINE

Why might a patient on Clozapine experience more infections?

Clozapine may cause agranulocytosis which reduces the number of granulocytes increasing susceptibility to infection

Why might a patient on Clozapine experience more infections? What is the mechanism for this?

Clozapine may cause agranulocytosis which reduces the number of granulocytes increasing susceptibility to infection Clozapine is metabolised by liver microsomes, peripheral blood neutrophils and their bone marrow precursors to a chemically reactive intermediate that has been postulated to be a nitrenium ion